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Report 



on 


The Social Insurance Program 


in 


Haiti 



FEDERAL SECURITY AGENCY 
Social Security Administration 
Division of Research and Statistics 

Washington, D.C. 

April 1951 





i 


Introductory Note 

In October 1949, Haiti enacted a Social Insurance Law which 
provides for work-accident insurance (workmen’s compensation) and for 
sickness and maternity insurance. In January 1950, the Government of 
Haiti requested technical assistance from the Government of the United 
States in the further development of that social insurance program. 

Technical aid was furnished by the Government of the United States 
under the authority of Public Law 535 (81st Congress), commonly known as 
the "Point Four” program,, The arrangements for cooperative work and 
sharing of costs were made with the Government of Haiti, especially its 
Department of Labor, by the Department of State, the Technical 
Cooperation Administration and the Social Security Administration of 
the Federal Security Agency. 

Study of the Haitian Social Insurance Law and of descriptive and 
statistical information pertinent to the operation of social insurance 
was supplemented by visits to Haiti in October 1950 and in February- 
March 1951° The results of the stucfy-, the conclusions and recommendations 
are summarized in the following Report, prepared for such value as it may 
have to the Government of Haiti in the further planning and implementation 
of its social insurance program. 



Io S. Falk, Director 
Division of Research and Statistics 
Social Security Administration 
Federal Security Agency 


Washington, D.C. 
May 7, 1951 



11 


Acknowledgments 


It is a pleasure to record my indebtedness to many who aided 
this study. 

In the United States, valuable information and advice was given 
by officers of the Department of State, the Institute of Inter-American 
Affairs, and the Pan-American Sanitary Bureau (WHO); and by my colleagues 
in the Federal Security Agency—in the Office of the Administrator, the 
Public Health Service, the UoSo Employees Compensation Commission (now 
in the Department of Labor), and the Social Security Administrationo 

In Haiti, cooperation and assistance were unfailingly and cordially 
given me by officers of the Government. It is a privilege to make special 
acknowledgment to His Excellency Paul Magloire, President of the Republic, 
Mr, Lelio Dalencourt, (formerly) Secretary of State for Labor, Dr, Camille 
Lhdrisson, Secretary of State for Public Health, and Mr. Francois Georges, 
Secretary of State for Finances; to Mr. Clement Jumelle, Under-Secretary 
of Labor, who conceived the project and carried general responsibility for 
facilitating the stuc^r; to Mr, Francois Latortue who was chief of the 
study staff; to Mr, Max Fouchard and others in the Bureau of Labor who 
gave extensive assistance; to Dr. Edward Loubeau, Administrator of the 
General Hospital, Port-au-Prince, and many other officers of the Department 
of Public Health; to Mr, Edward P. Swan and Captain Robert Bazile, Bureau 
of the Census; to Mr. Edwin Dudley and members of his staff in the U,S 0 
Sanitary Mission (I.I.A.A,); to Mr. A. J. Wakefield, U, N. Resident 
Representative for Technical Assistance; and to many private citizens 
representing employers, labor and civic groups, the medical associations 
and other groups interested in social insurance in Haiti. 

The Embassy of the U.S.A. in Haiti gave invaluable help, and I 
express my thanks to Ambassador William E. DeCourcy, Mr. John H. Burns, 
Charge d’Affaires, and to many other members of the Embassy staff— 
especially Mr. H. L. T. Koren. 

I am also grateful, for their technical and clerical assistance, 
to Mrs. Mary P. Nelson, Miss Mariella T. Richard, and to other members 
of my staffs in Washington, D.C. and in Port-au-Prince, Haiti. 


I. S. Falk 



May 7, 1951 



iii 


CONTENTS 


Chapter 


Page 


I. 

II. 

Ill, 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 


The Haitian Social Insurance Law of 1949. 


Some Major Questions of Social Insurance Policy.. 

Some Basic Statistics on Employment, Earnings 
and Disability..... 


ooooooooooooooooooooooooooooooq 


Present Resources for Medical and Hospital Care. 
Sickness and Maternity Insurance. 


Work Accident Insurance 


>0000000000060000000 


0000000000000000000060060000 


Medical Benefits in Port-au-Prince 


o o o o o 


o o o o © o 


The Provision of the Medical Benefits. 


oo»ooo«©oo*oo 


Administration of Social Insurance 


OQOOOOOOOO *060000 


Conclusions and Recommendations. 


o o o o o o o 


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1 

6 

17 

40 

64 

92 

102 

109 

118 

129 


Appendices 

A. 

B. 


Text of the Social Insurance Law, October 1949..... Al-20 

Work Accidents and Compensation on Three Sisal 
Plantations 000000000 . 00000 . 00 ...•oooeoo.oeo»»««»o® Bl—4 


Appendix Tables... 


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1-19 

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CHAPTER I 


The Haitian Social Insurance Law of 1949 

4 

In October 1949, Haiti enacted a social insurance law. It 
authorized the inauguration of a social insurance program and the 
establishment of an ’’autonomous” administrative institution—Institut 
d‘Assurances Sociales d*Haiti (iDASH).l/ 

The law provides for social insurance against work-accidents and 
against sickness (including maternity)., It does not provide for insurance 
against other common risks, such as old-age, unemployment or non-work- 
connected invalidity or death, which are often covered by social insurance, 

* l • •• V • * : 

The two social insurance programs established by the 1949 law have 
many common characteristics, but there are also some differences between 
them. The text of the law is given in Appendix A• The provisions are 
summarized here, before turning to their closer inspection. 

Social Insurance Against 

Work Accidents 

* 

The Law of October 1949 establishes a system of social insurance 
against work accidents—-what is commonly known as workmen 8 s compensation. 

It supersedes certain existing employees liabilities with respect to 
work-connected injuries and, in lieu thereof, provides stated benefits 
for the injured worker and his dependents. 

Coverage ,—Work-accident insurance is made compulsory in its 
coverage of public employees and of enployees in industry, commerce, 
private teaching establishments, domestic service and agriculture. In 
general, coverage extends to all manual or non-manual workers who render 
services for compensation under an express or implied work contract. It 
applies to all employers in covered industries, regardless of size of 
establishment, and to all of their enployees. It does not apply to 
family employment and to certain specifically excluded occupational groups 
(aliens employed in embassies, etc,; temporarily-resident technicians; 
military personnel; and clergymen). The term industrial accident 
(’’incapacite de travail’*) appears to be broadly defined so as to include 
occupational disease as well as direct accidental injury (art, 3(b)), 

There is no provision for voluntary coverage of employers or employees 
who are not compulsorily covered, 

. Eligibility for benefits .-—Insured status exists automatically 
for all coyered enployees upon and during employment. There are no 
limiting conditions for the attainment of insured status. 


1/ For background of the law, see Rapport Concemant L’Introduction 

des Assurances Sociales en Haiti , by Taddee Poznanski. Port-au-Prince, 
Haiti, (1945). 











£-2 - 


Benefits©— In case of work injury, the law gives the injured 

employee rights to medical and cash benefits,, He is entitled to medical 

benefits (medical, surgical, pharmaceutical, hospital, appliances, etc©) 

until he has completely recovered# In case of incapacitation, cash 

benefit is a daily compensation beginning with the fourth day after the 

accident and continuing throughout the period of incapacity© The rate of 

daily cash incapacity benefit is 50 percent of the employees basic wage, 

supplemented by 10 percent for each dependent, up to a family maximum 

of 70 percent© In case of permanent-total disability, the benefit is 

two-thirds of basic wage; and in case of permanent-partial disability, it 

is proportional to the degree of the disability© In case of fatal injury, 

the benefits includes (a) a funeral benefit equal to one month's basic 

wage; (b) a widow's pension equal to 50 percent of the benefit payable in 

case of permanent-total disability, or a similar pension at 30 percent 

rate to a surviving common-law wife; (c) an orphan's pension equal, for 

each child under 16, to one-fifth the disability benefit© There is a 

family limit of 80 percent of disability benefit for all widow's and/or 

orphan's benefits© Cash benefits are payable in the same manner as wages, 

but they are not payable if wages are being received© If partial wages 

are received, the benefit is reduced thereby® The incapacity of the 

recipient is subject to periodic review on request of IDASH© 

» 

Contributions ©—The cost of this insurance is entirely on the 
employer© The initial rate of contribution is 1 percent of the basic 
wages of employees© The rate may be changed (presumably upward and 
downward) by IDASH, with due regard for risks in the enterprises and 
safety measures taken by employers® This insurance relieves the enployer 
of other obligations, in respect to industrial accidents, under the Civil 
Code 0 

Social Insurance Against 

Sickness and Maternity 

The law of October 1949 establishes a system of insurance against 
sickness (non-work-connected) and maternity© 

Coverage ©—Sickness and maternity insurance applies to the sans 
classes of employed persons as are covered for work-accidents, except 
that the coverage is voluntary rather than compulsory for employees whose 
basic monthly wage exceeds $300©2 J Such exenpted employees may insure 
voluntarily on establishing freedom from sickness affecting capacity tad 
work© Employed persons who are insured (conpulsorily or voluntarily) may 
voluntarily insure their dependents for the medical benefits* 

Eligibility for benefits ©■ —The law specifies no requirements, as 
to prior insured status, for eligibility to receive medical benefits© 

In case of sickness resulting in incapacity, cash benefits are payable if 
the employee has been insured for 6 months and has paid contributions 
for 17 weeks; and in case of sickness resulting in death, the death 


2/ The gourde ($) equals 20 cents in the currency of the U©S®A© 












5-3 - 


benefits ai*e payable if the employee has been insured for 1 year and has 
paid contributions for 240 days e 

BenefitSo--Medical benefits in case of sickness (medical, pharma¬ 
ceutical, hospital, etc,) are available from the beginning of sickness for 
a maximum of 27 weeks for insured employees and for 13 weeks for insured 
dependentso The period may be extended by IDASH to 1 year in special 
cases# In maternity cases, the medical benefits are available on request 
of the insured person, and the hospitalization benefit on explicit request 
of the attending physician# 

Cash benefits in case of sickness are payable at the rate of 50 per¬ 
cent of basic wage for each day of incapacity from the fifth day of the 
illness and continuing throughout the duration of incapacity# The benefit 
rate is increased by 10 percent for each dependent, up to a family maximum 
of 70 percent# No second waiting period is required in the event of a 
relapse# In the event of death, a death benefit equal to 3-months* basic 
wage is payable to spouse, dependents or dependent parents# In maternity 
cases, the same cash benefits are payable for a maximum of 42 days (pre¬ 
ceding and following confinement)# Cash benefits are not payable if the 
incapacity was deliberately provoked, if the insured person performs work 
for which he is paid, or if he refuses to follow the instructions of the 
attending physician# Cash benefits are not payable when the insured 
receives a wage, except that if receiving part of his wage the benefit is 
reduced by the amount received# In a maternity case, paid domestic work 
consistent with her condition does not abrogate right to cash benefit# 

Contributions# — The cost of sickness and maternity insurance is 
divided between the employer and the employee# For compulsory insurance 
of employees # the contribution rate is 8 percent of basic wage, equally- 
divided between employer and employee, except that in the case of the 
employee with a basic monthly wage of less than $110 the charge is wholly 
on the employer# For voluntary insurance of employees # the rate is 6 per¬ 
cent, payable by the employee# For voluntary insurance of dependents, the 
rate is 5 percent, also payable by the insured employee# 

Administration of Social Insurance 

The social insurance law assigns administration to IDASH# This 
institution is to be managed by a Council ("Conseil d*Administration 1 *) 
having 9 members (3 representing the Departments of Labor, Public Health, 
and Finances, respectively, of the Government of Haiti| 3 representing the 
en?>loyers| and 3 representing the workers)# All 9 members are to be 
appointed by the Presidents the Government representatives from the 
technical personnel of the Departments % the employer and worker representa¬ 
tives from lists of nine persons each to be submitted by employer organiza¬ 
tions and by labor federations and unions, respectively# The Council 
members are to be ‘‘irremovable** and are to serve 3-year renewable terms# 

No member of the Council may also be Director or Assistant Director# 











5-4 - 


The Council is to elect its own officers, appoint the Director and 
one or more Assistant Directors (by two-thirds majority vote), determine 
the scope of their duties and control their operations, and establish 
regulations for the functioning of IDASH* The Council is to meet at least 
once a year, and also at the request of its Chairman, 3 of its members, 
or of the Director* 

The Director is to manage all affairs of IDASH except those 
reserved to the Council* He is required to make an annual report to the 
Council on operations and plans* He is authorized to manage the institu¬ 
tion; appoint and dismiss its personnel; prepare the annual budget and 
authorize approved expenditures; make arrangements with physicians, 
hospitals, etc*, for the provision of medical benefits; and he is to attend 
meetings of the Council in an advisory capacity® 

The financial resources of IDASH consist of contributions, interest 
and earnings, donations, fines, etc*, and a subsidy from the Government 
in an amount to be determined later* 

The Council is given authority to introduce conpulsory insurance 
in stages, taking into account the possibilities of registering employers 
and workers, collecting contributions, and providing the benefits* 

Employers are required to register themselves and their employees, 
as prescribed by regulations issued by IDASH, and to pay contributions to 
it by means of stamps or in cash* Employers are required to keep their 
payrolls for 2 years and in a prescribed form, and to submit the records 
for examination on request* In the absence of payroll records, IDASH 
determines the amount of contributions due from an employer who fails to 
pay contributions* Employers are authorized to make deductions from pay, 
and are responsible for payment of employee contributions from compulso¬ 
rily insured employees* Interest and penalties are prescribed in the law 
for failure to pay contributions when due* Penalties are also provided 
for other infractions, as in the case of employers who fail to meet their 
obligations to report accidents, to keep insurance cards or affix insur¬ 
ance stamps, or who interfere with inspections, or as in the case of 
employees who obtain benefits illegally* 

IDASH is to administer insurance against work accidents separately 
from other insurance, and to keep separate accounts and resources for it* 

IDASH is subrogated, up to the amount of costs incurred by it, in 
case an insured person who suffers an accident in the course of his work 
has a claim against someone other than his employer* 

IDASH is authorized to make rules to prevent abuse in demand for 
medical and related benefits* 


Sickness (and maternity) medical benefits are to be received 
insofar as possible in special dispensaries of IDASH, and—in the case 
of hospital care—in semi-private rooms of the public hospitals or in 
private hospitals with which IDASH has concluded a contract for such 
service, or in IDASH*s own hospitals. Insured persons electing private 
rooms are to pay the cost difference between a private and semi-private 
room. 

IDASH is required to invest funds not needed for current purposes 
the investments to be made with regard for security, yield and social 
utility| to use its funds for administration and benefits; for hospitals 
sanatoria, clinics, maternity homes and other buildings for the use of 
the insurance program; for the organization of national workshops and 
enterprises on .an income-producing basis; for loans and mortgages 
especially for low-cost housing or workers’ settlements; and for 
guaranteed interest-bearing loans to private welfare organizations 
(hospitals, asylums, etc.) and producers’'cooperatives. The proceeds 
from use of investment capital are to be used to improve the health and 
working conditions of workers. ^ 

■ .•* j> \ . • 

IDASH is given exemption from various taxes, customs duties, 
etc., and immunity from attachment of its property, funds and income. 

The Law of May 17, 1943, which created .the Social Insurance Fund, 
is repealed and the assets of that Fund are transferred to IDASH for a 
working capital and guarantee fund and for liquidation of claims (if 
any) under the previous law. 

In order to meet initial expenses of organization, IDASH is 
authorized to delay benefits up to 6 months beyond the date on which 
it begins to function. * 

Decisions made by IDASH—with respect .to obligation to be 
insured, contributions, rights of insured persons, benefits, etc.—are 
subject to judicial review.on appeal to the civil courts. 

All laws and provisions in conflict with this social insurance 
lav/ are repealed. 

Activation and Suspension of the Law 

The Social Insurance Lav/ remained inactive after its enactment 
in October 1949, v/hile the Government of Haiti., was awaiting the 
availability of a foreign expert adviser. In July 1950, prior to his 
arrival, the Lav/ was activated, the Conseil d *A dministr a tion and the 
Director were appointed, and preliminary steps were taken to acquaint 
employers with the specifications of the law and obligations to be 
registered and to pay contributions. Serious criticisms were then 
raised by certain employers; and, on September 28, 1950, the interim 
Government decreed the indefinite suspension of the Lawr. This was 
the status throughout the present study. 






- 6 - 

CHAPTER II 


Some Major Questions of Social Insurance Policy 

The primary question to ■which the survey is addressed is how 
Haiti may best proceed in establishing the social insurance system (or 
systems) authorized by its law and, accordingly, what kind of further 
technical assistance the United States may be able to give, This report 
is therefore devoted, in general, to analysis of the law, identification 
and inspection of the main problems which it appears to present for 
Haiti, and the development of recommendations for dealing with those 
problems. 

Should the Social Insurance Law be Implemented ? 

Before turning to an analysis of the law or a consideration of 
specific problems, there is a basic question whether the social 
insurance law should be implemented at all, This question was 
occasionally raised by persons consulted in the course of the surveyo 

It should first be recorded that no criticism of the law has 
been encountered—and none is being expressed here—-because of its 
less-than-comprehensive scope as a social security or as a social 
insurance program. From all appearances, it was a sound decision for 
the 1949 Law to omit insurance against old age, invalidity, ileath of 
the wage earner (from non-work-connected causes), and unemployment, 
and for it not to propose to establish any new comprehensive program 
of public assistance at this time. 

In its present stage of development, Haiti has an acute 
population problem in relation to its current resources. The popu¬ 
lation and the econony are largely dependent on small-scale, under¬ 
developed and undeveloped agriculture. There is a relatively large 
amount of unemployment and under-employment, reflecting a massive 
over-hang of the self-employed agricultural population over the labor 
force engaged in commerce, industry, organized agricultural employment, 
and public administration. In addition, Haiti has almost overwhelmingly 
pervasive and acute health needs, and it suffers from large inadequacies 
of health personnel and facilities. 

With its acute lack of economic resources, Haiti has only minimal 
flexibility in the uses to be made of such resources as it has, Haiti 
cannot at this time undertake comprehensive public insurance programs 
to ensure maintenance of income for the aged or the disabled, for those 
left dependent by premature death of the breadwinner, or for those who 
are unemployed, A large proportion of those who need assured continuity 
and maintenance of income have little income to assure and they have 
very little income derived from earnings which they can devote to 
paying for such assurance. Most of them have no employers—or only 
intermittent employers—to help pay the cost. And the cost of living 




H-? - 


cannot now afford substantial increase such as could result from employer 
insurance costs passed on to consumers <> Certainly ary programs, 
insurance or other,, that would involve a combination of pay-roll 
deductions and reserve financing would have to be carefully safeguarded 
against adverse effects on consumption and standards of living. 

Nor can Haiti undertake any comprehensive program of public 
assistance for the needy poor. A large proportion of Haiti’s entire 
population is very poor; and a large proportion is tragically poor by 
physiological, health, economic, educational, cultural or social 
standards. Any substantial provision of public assistance for the 
poor would involve public funds far larger than anything that the 
Government can coiunand. 

As a practical matter, Haiti can consider at this time only a 
limited social security program—perhaps only such a limited program 
as it has embodied in its Law of October 1949. 

Further consideration focuses on the two insurance systems 
embodied in the Law—whether they are needed, whether they can be 
afforded, and whether they hold reasonable promise of being established 
and administered successfully. 

Should Haiti Proceed with Work-Accident Insurance ? 

All information accumulated in the course of the survey indicates 
that the decision to introduce a system of workmen’s compensation in 
Haiti is sound in principle. 

The liability of the employer for the consequences of work- 
connected injury is established by the provisions of the Haitian Civil 
Code (Articles 1168 and 1169). Discharge of that liability, however, 
is inadequate—it is uneven, complicated and controversial. There is 
also reason to be concerned that the existing provisions and practices 
will become more inadequate if or as industry and comnerce become 
larger sectors of the economy, and a larger proportion of the population 
and the labor force becomes wage earners. 

World-wide experience shows that a system of workmen’s compen¬ 
sation can become an effective means of requiring employers to meet 
their liabilities arising out of work accidents and injuries; and it 
can provide an orderly, and in a large proportion of cases of work 
injury, an automatic, system of discharging that liability. If the 
system is well designed and well administered, it may also be expected 
to strengthen the economic security of employees by providing prompt 
and adequate benefits; to improve employer-employee relationships by 
largely eliminating controversy from the field of work-injury compen¬ 
sation; to lessen the costs of work injuries for many employers by 
reducing fraudulent claims and malingering (reported to be unduly 



In¬ 


frequent in Haiti), by reducing or eliminating the costs of lawyer’s 
fees and court cases and by encouraging accident-prevention ; and to 
stimulate and support a program to provide more adequate care and 
rehabilitation for injured workers* Such a system need not involve any 
substantially larger cost than is already incurred by employers in 
meeting their liabilities, except insofar as it would compel some 
employers to meet obligations which they are not now meeting,. To the 
extent that the insurance system would result in more extensive 
compliance with employer liability, it would help to equalize the costs 
for work-injuries among employers who do and those who do not 
conscientiously observe their obligations to absorb these costs as part 
of the cost of employment* 

It will appear later that a substantial system of workmen f s 
compensation would probably cost (uniformly, or on the average among 
employers) about 1 percent of payroll* The cost might work out to be, 
on the average, somewhat less than 1 percent $ it might prove to be 
somewhat more, but is not likely to be more than 1*5 percent or to 
reach 2 percent* Such a cost is within Haiti 1 s means, especially since 
most or all of it is already being incurred and met in one way or another* 

The need for medical services arising out of work-connected 
injuries is a relatively small proportion of total medical need* The 
establishment of a system of workmen’s compensation may be expected to 
increase the amount of care that has to be furnished in work-connected 
cases* But the aggregate increase would not substantially change the 
total load on the nation’s available resources for medical care, 
especially if this insurance covers only a small fraction of the 
population* Consequently, the inauguration of workmen’s corrpensation 
does not have to depend on large-scale expansion of the available 
resources for medical care—though, as will appear later, it may well 
demand some adjustments and improvements in certain areas where resources 
are deficient* 

All such considerations endorse the decision to establish a 
system of workmen’s compensation for work-accidents and injuries* There 
are, however, many important details of the program which need recon¬ 
sideration, e*g*, the coverage of the insurance and especially whether 
or not to include agricultural employment, the contribution rate and 
its graduation among employers, the specifications for the benefits, 
the provisions for administration, and whether to institute the program 
for the whole intended coverage and throughout the country or to 
develop it in a series of geographically as well as occupationally 
limited stages. These will be considered later, in connection with 
similar questions applicable to sickness and maternity insurance and 
to inter-relations of the two insurance programs* 


Ii-$ - 


Does,. Haiti Need Sickness and Maternity Insurance ? 

There are many differences of opinion or, more precisely, many 
reservations among Haitians concerning the decision to introduce 
sickness and maternity insurance 0 These are not focused on the 
desirability of having provisions for a worker*s income maintenance 
during periods of incapacity or for having improved assurance that 
workers and their dependents will have access to needed medical care* 
Rather, the reservations arise out of more limited and more specific 
practical considerations, focused on ways and means of establishing 
the insurance system, administering it, paying its costs, and— 
especially—providing its medical-care benefits. Each of these questions 
will be examined in some detail later; their more general aspects may 
be considered here. 

Cash benefits o—The money benefits to be provided by the sickness 
and maternity insurance are intended to serve as partial replacement of 
wages lost during periods of incapacity. Such benefits are important 
for any group of wage earners. They are especially important for wage 
earners in Haiti. Large proportions or most of the persons in Haiti 
who are employees earn wages only barely-—if at all-sufficient for 
subsistence. Employment is irregular and uncertain for many of them. 

Most of those who are normally dependent on current money earnings have 
little or no accumulated reserves upon which to draw when incapacitated. 

It is sound that an insurance system should provide cash benefits for 
wage-loss, and there do not appear to be any insurmountable difficulties 
in organizing the administrative arrangements for providing these 
benefits. 

Medical benefits .—While not minimizing the importance of the 
cash (wage-loss ^ benefits, emphasis must be placed on the medical benefits 
as the more important of those proposed by this insurance. Poverty among 
the Haitian wage and salary workers is matched by ill health among them 
and their dependents. These two plagues—poverty and ill health—are 
interlocked and inter-related; each begets the other. An attack upon 
one is also an attack on the other, in whichever sequence they are taken. 

Haiti*s program for general economic rehabilitation, which is 
receiving the active attention of the Government, must be comprehensive 
and long-range. As is well appreciated, it must from the very beginning 
include an attack on the health problems; otherwise the whole program 
of national progress may be doomed to failure. People who are sick 
cannot work hard, persistently or well; they cannot be highly productive. 
The sickness and maternity insurance system offers a meanscf supporting 
a major part—the most expensive part—of a new attack on ill health 
among wage and salary workers in Haiti. Like any other program designed 
to improve hospital and medical services, the insurance will be all the 
more successful, and all the less expensive, the more it provides 
effective preventive services and the more it is coordinated with 






IMP - 


community-wide and personal preventive services furnished by the public 
health and related programs» Sickness and maternity insurance, 
developed in conjunction with public health programs, offers a new 
(opportunity for a greatly strengthened and expanded health program for 
H&iti* This may be regarded as probably the most important single 
ueason for undertaking to establish this insurance system* 

It will appear later, when examining the details of Haiti*s 
present resources for hospital, medical and related services, that the 
country's hospitals, clinics and medical personnel are quite inadequate 
to meet current needs 0 The insurance system would not, of itself, 
increase need for hospital and medical care* However, to the extent that 
application of the insurance principle brings hospital, medical and 
related services within the financial reach of the insured population, 
the system will increase effective demand for the services, and it may 
very greatly increase that demand 0 Having regard for the present 
inadequacy of medical resources, without insurance, it has to be 
expected that they would be even less adequate in the face of augmented 
demand after insurance comes into operation,. Thus, the capacity to 
provide services must be increased before insurance benefits become 
due, or the insurance beneficiaries must be given priority in the 
receipt of care from existing facilities and personnel 0 Otherwise, 
the insurance system would fail to meet the obligations incurred as a 
result of the collection of ear-marked contributions and its promise to 
provide medical and related benefits* Such a failure must not occur* 

The increased effective demand for medical services must be 
expecteds and the claims for insurance benefits must be anticipated* 

J&e resources for service must be increased, or earmarked in appropriate 
measure for the insurance beneficiaries, or both* The increase in 
effective demand and in the capacity to supply services must be 
synchronized* The capacity to meet the augmented demand for medical 
benefits which is to be expected under the insurance system determines 
whether or not, and when, sickness and maternity insurance can be 
implemented* 

The Social Insurance Law of October 1949 gives broad authori¬ 
zation to IDASH to provide the medical benefits or to arrange for their 
availability to insured persons* The authorization extends to the 
construction and operation of hospitals and clinics, the employment of 
medical and other personnel, etc*, as well as to the use, by contract, 
of public? 'and private facilities and practitioners* Thus, the insurance 
medical benefits may be provided through IDASH*s own system of medical 
resources, through the existing public and private facilities and 
personnel, or through a combination* The course to be followed in the 
choice (or choices) among these alternatives are fundamental for the 
plans of this insurance system* If the system has large coverage— 
sooner or later on, the decision about the provision of insurance 
mgdical benefits is very important for the hospital and medical system 
of the countuy'* 



I5-£L - 


Haiti now has a dual system of medical care® It has some private 
hospitals, clinics and practitioners® More importantly, it also has an 
extensive national system of public hospital and medical service, 
administered by the national Department of Public Health and financed 
out of the general revenues of the national Government® If sickness 
and maternity insurance is established and IDASH undertakes to supply 
the medical benefits through its own medical resources, Haiti will 
have a triple system® 

In the event the insurance system is established, which course 
(or courses) may or should be followed by IDASH in assuring that the 
medical benefits are available to the insured persons will be considered 
later® At this point, the question is whether an insurance system is 
needed to improve the medical service of the Haitian population® Or, 
to pose the question in another ways How else, except through an 
insurance system, can Haiti develop its medical services? Two 
alternatives may be considered® 

Can Haiti strengthen its medical resources which are provided 
by private practitioners and agencies and supported by private fees? 

As indicated elsewhere in this report, the private resources are very 
limited® Their development through private resources alone to the 
point of being able to meet the obligations of the insurance system is 
not to be anticipated for the discernible future •, it cannot occur until 
the Haitian people have greatly increased financial means® Conversely, 
it is not altogether reasonable to expect that the Haitian people can 
come to have such increased financial resources unless they build up 
more adequate health and medical services® Thus, this approach is 
"circular," and is not fruitful® 

The second alternative is through the public hospital and clinic 
system® This system is intended primarily for the poor® But since most 
of the people are poor, and since practically all (in a statistical 
sense) are substantially indigent when confronted by the costs of a 
serious or extended illness, the public system is in effect a system to 
serve, potentially, nearly the whole population® It is widely agreed 
throughout Haiti that the present public system cannot and does not 
meet its intended obligations or the public need now® Its facilities 
and resources are insufficient® There is also general agreement that 
improvement must depend basically on receiving much larger financial 
resources than are available to the public system now—as well as on 
effecting administrative and other improvements® 

If economic conditions improve and continue to improve in Haiti 
generally, the Government may become able to appropriate more for the 
support of its public hospital and clinic system® But something 
approaching adequacy in this public system demands very large increases 
in capital funds and several times as much in annual maintenance funds 


-12 - 


as is now available* Such relatively large-scale and extensive 
expansion would put a heavy drain on the national Government* a heavier 
drain than can be anticipated with composure or confidence at this 
time-having regard for the many other pressing public needs and 
especially for the very limited sources of continuing revenue for 
Haiti's public purse* A large proportion of the revenue of the Haitian 
national Government derives from export and import duties—generally 
regressive sources of revenue* A greatly enlarged system of public 
medical services supported by general revenues is presumably not a 
practical alternative* 

It would obviously be sinpler for Haiti to have* in addition to 
its private medical services* only its system of public hospitals and 
clinicso It will be more complicated to have its present dual system* 
and* in addition* a system of medical-care services supported through 
an insurance system* But it appears that Haiti must find an additional 
source of financial support for its medical services—as through earmarked 
social insurance contributions—or must continue with grossly inadequate 
hospital, medical and related services* 

Thus* the practical issue about the wisdom of establishing 
sickness and maternity insurance is whether to accept the present situ¬ 
ation and hope that some improvement will become possible when* as* and 
if the level of the econony and the financial position of the Government 
will permit| or whether to attempt to augment the resources for medical 
care by such a method as is offered by an insurance system* Stating the 
issue in this form invites the conclusion that improved medical services 
must* as a practical matter* depend on the new sources of revenue which 
may be provided by social insurance* and that it is sound to establish 
such a system* 

This conclusion does not of itself determine whether the medical 
benefits should be provided through one system of arrangements or another* 
It only argues for the need for the insurance system and its financial 
resources* 

At this point the conclusion my be expressed that the survey 
confirms the need for a social insurance system to assure not only 
continuity of some income when the wage earner suffers incapacity (non¬ 
work-connected)* but also to assure access to needed medical care and 
to provide the funds necessary to support both the wage-loss and the 
medical-care benefits* 

As in the case of the system of workmen's compensation* the 
sickness and maternity insurance presents many specific problems that 
need resolution—concerning the coverage of the insurance system* where 
when and for which groups to be instituted* the premium* the conditions 
determining eligibility for benefits* the specifications for the cash 

benefits* how the medical benefits shall be provided* and administration 
generally* 


13 - 


Should Haiti Start with Both Insurance Systems ? 

The preceding considerations suggest that, in principle, it is 
sound for Haiti to plan—as in the Social Insurance Law of October 
1949 =—upon developing social insurance for the risks of work accidents 
and of sickness and maternity,. 

If the Government of Haiti decides tentatively to proceed with 
plans to bring such insurance into force, it is confronted with some 
important questions which must be faced and answered at the outset 0 
Then, after it has formulated answers to these questions and considered 
the implications and consequences of those answers, it must decide 
whether the tentative decision to proceed should become firm and 
definitive,. 

If the tentative decision is to proceed if possible, a first 
major question is whether it should start with both insurances, despite 
the practical difficulties! or whether, in the alternative, it should 
start with only one insurance and should choose the one which presents 
the fewest and least initial difficulties, 

A correlated major question is the initial extent of any social 
insurance system which may be undertaken, "Extent 0 involves three 
basic dimensions : (l) Geographical application , whether to be established 

at the outset throughout the country, or only in limited areas; 

(2) Employment coverage, whether to apply to all gainfully occupied 
employees, or only to those in specified classes of employment; and 

(3 ) Scope of benefits * whether to provide for all classes of needed 
benefits, or only for those most urgently needed and most readily 
available. 

It should be noted that the Law of October 1949 authorized the 
establishment of a nation-wide insurance, with coverage of substantially 
all employees, and with provision of comprehensive wage-loss and medical 
benefits« However, the Law also recognized potential difficulties; and 
accordingly it provided (article 4) that HASH 8 s Council of Adminis¬ 
tration is authorized to introduce compulsory insurance in stages, taking 
into account the possibilities of registering employers and employees, 
collecting contributions, and providing the benefits. Thus, there is 
already provision in the law for flexibility, through administrative 
decisions, in the initial and subsequent extent of application of 
either social insurance or of both systems«l/ 


1/ The text of article 4 is here interpreted as authorizing flexibility 
with respect to each of the three dimensions (geographical, employ¬ 
ment, and scope of benefits) c If this interpretation is incorrect 
or uncertain, the text of the law may need reconsideration and clari¬ 
fication in light of decisions that nay be taken on these questions 0 







The difficulties which confront Haiti in inaugurating social 
insurance arise from its limited resources for meeting the special 
needs of such a program—trained and experienced administrative 
personnel, administrative machinery, under standing on the part of 
employers and employees of social insurance and its operations, and 
personnel and facilities for providing hospital and medical services,, 

In all of these respects, Haiti is severely disadvantaged in meeting 
the problems and demands peculiar to social insurance, especially in 
the inaugural stages* It is therefore obviously advisable that, if 
Haiti decides to go forward with its social insurance program, it should 
consider making only a minimal beginning| and that it should contemplate 
a subsequent gradual expansion—as initial administrative and other 
problems are solved, as experience accumulates, and as personnel and 
other resources increase,, 

This line of reasoning immediately suggests that Haiti should 
consider starting with only one insurance system—as against two* If 
one is to be chosen on these grounds, it would appear that it should 
be insurance against work accidents ("workmen’s compensation) rather 
than insurance against sickness and maternity* It is not surprising 
that this proposal was frequently met in the course of the survey * 

And it is in a pattern which has been followed in nearly all countries 
which have enacted social insurance programs* 

A plan to start with only workmen’s compensation has advantages 
for an initial undertaking 0 On balance, it is probably simpler to 
administer than a system of general sickness and maternity insurance* 
Some of the important reasons for this conclusion deserve specific 
mentions 

(a) Both systems of insurance involve the registration of 
employers and their preparatory education for effective 
participation* But workmen’s compensation does not-— 
and sickness and maternity insurance does—involve 
registration of employees and their dependents* 

(b) Workmen’s compensation involves contributions only from 
enployers, with the amount of contribution probably 
measured in relation to total salaries and wages* 

Sickness and maternity insurance involves contributions 
from both employers and employees, and probably requires 
contributions complicated by special adjustment to the 
amount of salary or wage paid to individual employees* 

(c) In workmen’s compensation, coverage and insured status 
for workers follow directly and immediately from and 
upon establishment of the employment relationship, and 
the insurance continues automatically throughout 
employment* Sickness and maternity insurance, 


T - -15 - 


especially if the coverage of the system is limited,, 
requires a system of eligibility requirements and 
determinations, probably involving difficult and 
complicated administration as well as extensive 
public understanding*, 

(d) Workmen's compensation ordinarily involves only about 
5~10 percent as many claims for benefits as arise in 
sickness and maternity insurance for equal coverage,, 

(e) The medical benefits of workmen's condensation may be 
within the capacity of existing personnel and facilities, 
or may require only relatively small expansion and 
adjustment*, Sickness and maternity insurance with 
extensive coverage is probably wholly impractical unless 
and until the resources for medical, clinic and hospital 
services are substantially expanded,. 

There are some important offsetting disadvantages to starting 
with only workmen's compensation, and those disadvantages should also 
be appreciated? 

(a) Workmen's condensation involves administration of 
some classes of benefits which are not provided by 
sickness and maternity insurance (e*,g c , pensions for 
long-term or permanent disability, for partial 
disability, and for widows and orphans in fatal cases)„ 

(b) Workmen's compensation nay involve graduation of 
employer contribution rates according to risk-rates 
based on experience*, This is a complex administrative 
function which does not and need not arise in sickness 
and maternity insurance*, 

(c) An insurance system which assumes responsibility only 
for work-connected cases of injury or only for non- 
work- connected cases requires a determination of work- 
connected causation in every claim for benefits. This 
involves a difficult administrative function, especially 
if the employer’s contribution depends on the risk-rate 
for his own establishment» The administrative task has 
to be more precise and is more difficult if there is 
only workmen’s conpensation*, 

(d) Unless an initial system of workmen’s compensation is 
designed with foresight for relations to the design of 
a future system of sickness and maternity insurance, 
its specifications may tend to predetermine future 


patterns for benefits (kinds, amounts, duration, etc 0 ) 
and may make future developments more complicated and 
more difficult« 

(e) Starting with only workmen’s compensation, a social 
insurance program deals with an important need, but 
still it deals only with one which is relatively small 
by comparison with the larger need that calls for a 
general system of sickness and maternity insurance 0 
Such a limited initial program may tend to postpone 
badly needed, concerted, efforts to enlarge and 
improve the hospital and medical facilities of the 
country 0 It cannot make more than a very limited 
contribution to badly and urgently needed improvement 
of the public health 0 

The disadvantages may not outweigh the advantages of starting 
with workmen’s compensation alone 0 However, they suggest that an 
initial establishment of workmen’s compensation should be undertaken 
not as the first of two more or less separate social insurance systems, 
but as the first step in the development of a comprehensive and 
coordinated (indeed, possibly an integrated) insurance system that 
will cover both workmen's compensation and sickness and maternity 
insurance,, 

On this basis, and appreciating the possible eventual advantages 
of coalescing the two systems, both social insurances provided in the 
Law of October 1949 need careful review to minimize differences between 
them, in order to provide for maximal future coordinated development 
and integrationo Thus, if the inadequacy of medical, clinic and 
hospital resources and other reasons dictate starting with less than 
the conqprehensive system, the initial plans should consider 
(a) Inaugurating the system of workmen's compensation3 (b) developing 
a program for meeting the needs of sickness and maternity insurance, 
especially by augmenting the resources for hospital, medical and 
related benefits; (c) fixing a time-table for undertaking the successive 
stages of development; and (d) providing for the finances of the 
developmental program,. 


- 17 - 
CHAPTER III 


Some Basic Statistics on Employment . 

Earnings and Disability 

TTien this study was undertaken, it was known that basic infor¬ 
mation was lacking in Haiti on population, labor force, family 
composition, earnings, and other subjects which have to be considered 
in an evaluation of the social insurance program. There was almost no 
statistical basis for even elementary estimates of the potential coverage 
of the insurance systems, the earnings of the persons who would become 
insured, the earnings that would be subject to the contribution rates, 
the numbers who would become eligible for benefits, the probable costs 
of the benefits, etc. 

Accordingly, plans were made for the compilation of such 
information as could be had from existing resources and to develop 
badly needed data through special surveys to be conducted by the 
Statistical Service of the Bureau of Labor, 

The preliminary population counts of the Census of 1950 became 
available in provisional form in October 1950 and in definitive form 
early in 1951.1/ They provided basic data on population for Haiti as a 
whole and for geographical subdivisions. The distribution of the 
population (3d million persons) by d^partements and arrondissements is 
shown in Appendix table 1. There are no corresponding data for Haiti 
on labor force, family composition, etc,2/ 

Private Employment; Urban 

A survey of private (urban) employment was made as of April 15, 
1950 in Port-au-Prince and in nine provincial towns. It covered 460 
industrial and commercial establishments in the capital city, and a 
sample of employing establishments in the other main cities and towns. 

The schedule applied to regular and administrative employees; it 
excluded the short-term seasonal farm workers engaged by some of the 
establishments. 


1/ Recensement de la Republique d 9 Haiti: Premier Denombrement de la 
Population (Ao#t 1950), Bureau de Recensement, Department de 
L’Economie Nationale, 1951. 

2j Some general data on employment in. 1943 are summarized in the UN 
report Mission to Haiti (July 1949, po 32), and data on earnings are 
also given in the source document ( Monthly Labor Review ,, U.S„ Department 
of Labor, October 1944, pp. 747-48). It was estimated that there were 
132,000 persons then employed for wages and salaries. But that estimate 
was heavily weighted by the large number of agricultural employees 
temporarily engaged in the Shada Cryptostegia- rubber project. The data 
on other employments and on earnings levels and distributions are also 
inapplicable to present conditions in Haiti. 









- 18 - 


Altogether, the survey covered establishments with 4,240 
employees—2,642 in Port-au-Prince and 1,598 in the provincial towns. 

The survey in Port-au-Prince covered about 10 percent of the 
total number of employees in private employment reported by the city 
census of 1949. But since that census included domestic servants, the 
survey probably covered a much larger percentage of those employed in 
commerce and industry. The survey covered 460 establishments. This 
suggests that it extended to about one-fourth of all establishments, 
and may have reached one-fourth of all employees in all such establish¬ 
ments. Corresponding ratios for the provincial towns are not available. 

Port-au-Prince 


The 1949 census of the capital city showed the following for 
the labor force: 


Total.............. 




Employed. ............... 

... 53,203 



Unemployed... 

0.0 24,912 



The employed persons were divided as 

follows s 



Employment 

Total 

Men 

Women 

GovBminsnt) «o*«ooo*oooeo«*««oo 

00000000 Cj p Q33 

5,903 

1,085 

Employees.................... 


11,975 

14 ,522 

Family employment (without 




remuneration).............. 

.. 0.0000 1,i70 

324 

1,046 

Employers (with employees)... 


1,277 

565 

Self-employed (no employees). 

.aoo.ooo 12 ,443 

4,137 

8,306 

NO*t I , 6 pOI't' 6 do 00060 OOOOOOOOOOO 

000000*0 4 * J 0^3 

1,638 

2,425 


The special survey did not cover large establishments located 
in the environs of Port-au-Prince (the sisal plantations, the 
distilleries, etc.) which are estimated to have an average of 400 
regular employees. Hasco, which operates the largest sugar refinery in 
Haiti, did not furnish data.2/ The survey was not able to obtain 
information on stability of employment and turnover. 


2/ It is known from other sources that Hasco has an average of about 
800 salaried employees and factory workers, uses 6,000-7,000 
additional workers during the harvest, and pays a minimum wage of 
$5 per day. 














- 19 - 


Full-time employment is generally 12 months $ it is 8-9 months 
in the cooking-oil factories, coffee establishments and distilleries, 
and about 6 months at Hasco, 

Provincial Towns 


The survey in these towns does not cover the employees on the 
large sisal plantations, or in the lumber and the essential oil 
factories, the Dessalines sugar mill, or the fig and banana plantations 0 

Sex. Marital Status, and 

Dependent Children 

The general characteristics of the 4,240 employees in the surveyed 
establishments are show, in table 1, 

In Port-au-Prince, 68 percent of the employees were males and 
32 percent were females$ but in the provincial towns females were in 
substantially lower proportion and accounted for only 20 percent. 

The distributions by marital status differed somewhat between 
Port-au-Prince and the other towns, the proportions married and living 
alone being slightly higher in the capital. 

The proportion employed on a monthly basis was substantially 
lower in Port-au-Prince (58 percent) than outside (74 percent). 

The 4,240 persons employed in the surveyed establishments had a 
total of 4,131 dependent children (approximately 1 such child per 
employee), of which 3,453 or 84 percent were under 16 years of age. 

The percentage of the children who were under 16 years of age was 
substantially higher in the provincial towns (89 percent) than in 
Port-au-Prince (80 percent). 

The corresponding data for each of the 9 provincial towns are 
shown in Appendix table 2. 

Size of Establishment 


Data were available on the distribution of employees by size of 
establishment for the places surveyed in Port-au-Prince and in 8 of 
the 9 provincial towns (table 2 and Appendix table 3)« The figures 
cover 2,567 employees in 416 establishments in Port-au-Prince, and 
1,254 employees in 252 establishments outside of the capital. 

The surveyed establishments were only slightly larger, on the 
average, in Port-au-Prince than in the provincial towns ; the average 
numbers of employees per establishment being as follows % 






- 20 - 


Table 1 

Some Characteristics of Employees in Private Employment 
(Based on a special survey, April 15, 1950) 



Total 

Port-au-Prince 

Provincial 
towns 1/ 


Number 

Percent 

Number 

Percent 

Number 

Percent 

Total employees. •. 

4.240 

100.0 

2.642 

100.0 

1.598 

100.0 

By sex:... 

4.240 

100.0 

2.642 

100.0 

1.598 

100.0 

Male.. 

3,088 

72.8 

1,805 

68.3 

1,283 

80.3 

Female. 

Not reported. 

1,151 

1 

27.1 

(2/) 

837 

31.7 

314 

1 

19.6 

.1 

By marital status:.... 

4, 240 

100.0 

2,642 

100.0 

1.598 

100.0 

Married. 

1,154 

27.2 

740 

28.0 

414 

25.9 

Place''!. ... 

1,143 

27.0 

602 

22.8 

541 

33.9 

Living alone. 

1,865 

44.0 

1,249 

47 »3 

616 

38.5 

Not reported.. 

78 

1.8 

51 

1.9 

27 

1.7 

By employment:.. 

4.240 

100.0 

2.642 

100.0 

1.598 

100.0 

Monthly. 

2,721 

64.2 

1,549 

58.4 

1,178 

73.7 

Weekly. 

1,408 

33.2 

1,056 

40.0 

352 

22.0 

Not specified. 

111 

2.6 

43 

1.6 

68 

4.3 

Dependent children: 

Total number. 

- 4,131 

100.0 

2.404 

100.0 

1.727 

100.0 

Number under 16 

years of age. 

3,453 

83.6 

1,921 

79.9 

1,532 

88.7 

Employees reporting 
incapacitating sick¬ 
ness (in last 12 

months).. 

2/888 

2/20.3 

453 

17.1 

2/435 

2/28.2 


1/ The provincial towns covered by the survey are: Fort Liberte', Cap-Haitien, 
Port-de-Paix, Gonaives, St. Marc, Jacmel, Petit Goave, Jdr^mie, Les Cayes. 

2/ Less than 0.05 percent. 

2/ Excluding one of the provincial towns (Petit Goave). 






























- 21 - 


Table 2 

Employees in Private Employment by Size of Establishment 
(Based on a special survey, April 15, 1950) 1/ 


Port-au-Prince All cities 


Size of Number Percent Number Percent 

establishment ---—-—-——-------— 


(Number of 
employees) 

Estab¬ 

lish¬ 

ments 

Em¬ 

ploy¬ 

ees 

Estab¬ 

lish¬ 

ments 

Em¬ 

ploy¬ 

ees 

Estab¬ 

lish¬ 

ments 

En>- 

ploy- 

ees 

Estab¬ 

lish¬ 

ments 

Em¬ 

ploy¬ 

ees 


93 

93 

22.4 

3.6 

153 

153 

22.9 

4.0 

2 

*~®OCOOOOO© 

82 

164 

19.7 

6.4 

137 

274 

20.5 

7.2 

3ooeoo©ooo 

51 

153 

12.3 

6.0 

94 

282 

14.1 

7*4 

^ © « o © © © ® o © 

41 

164 

9.9 

6.4 

67 

268 

10.0 

7.0 

0*00 © © ©t» 

23 

115 

5.5 

4.5 

31 

155 

4.6 

4.1 

£ 

27 

162 

6.5 

6.3 

35 

210 

5.2 

5.5 

^ © o o o o ©• © ® 

9 

63 

2.2 

2.5 

19 

133 

2.8 

3.5 

£> 10 9 © © e o o 

37 

333 

8.9 

13.0 

51 

459 

7.6 

12.0 

H "** 13 © 0 • 0 © © 

25 

325 

6.0 

12.7 

36 

468 

5o4 

12.2 

16 = ” 

17 

351 

4.1 

13.7 

28 

564 

4.2 

14.8 

<.£» — 49 0 . 0 0 0 0 

7 

231 

1.7 

9.0 

12 

366 

1.8 

9.6 

50 - 99 0 c 0 0 . . 

2 

120 

.5 

4.7 

3 

196 

.4 

5.1 

100 - 199.0000 

2 

293 

.5 

11.4 

2 

293 

.3 

7.7 

.H.lj„* © 0 *» oo© 

416 

2,567 

100.0 

100.0 

668 

3,821 

100.0 

100.0 


1/ Includes regular and administrative employees only. 








- 22 - 


In Port-au-Prince .6.2 persons 

In the provincial towns.... 5.0 persons 

In all establishments.. 5.7 persons 


The proportionate distributions of establishments and employees 
(cumulative), according to size of establishment, are shown in table 3. 

In general, about two-thirds of the establishments had 4 or 
fewer employees, and they account for only about 25 percent of all 
employees. Nearly 90 percent of the establishments had 10 or fewer 
employees, and they account for about half of all employees. The 
other half of the employees were in the 104- percent of establishments 
with 10 or more employees each. 


Earnings 

Information on earnings was supplied for 4,153 of the 4,240 
employees in the surveyed establishments. Their distribution by 
earnings are shown in tables 4, 5 and 6. The earnings categories used 
in these tabulations were selected for their pertinence to the 
proposed social insurance contribution requirements. 

The average earnings may be summarized as follows 


All 


Port-au- Provincial 
Prince towns 


All employees 

Per month: 0 . ... 188 

$... 37.60 

Per year: 0. . 2,256 

$...... .. 451.20 

Employees with monthly earnings 


Per month: 0 . ......... 153 

$.... 30.60 

Per year: 0... 1,836 

$.... 367.20 

All employees, but excluding 


Per month: 0. . 172 

♦ .. 34.40 

Per year: 0 . . 2,064 

.. 412.80 


210 

42.00 

2,520 

504.00 


159 

31.80 

1,908 

381.60 


185 

37.00 

2,220 

444.00 


153 
30.60 
1,836 
367.20 


143 

28.60 

1,716 

343.20 


149 

29.80 

1,788 

357.60 


Lj The Haitian gourde and the U.S.A. dollar are directly interchangeable 
in Haiti at the rate of 5 gourdes to the dollar. 



























- 23 - 


Table 3 

Cumulative Percentage Distributions of Establishments and 
Employees in Private Employment 


(Based on a 

special 

survey. 

April 15, 

• 

1950 ) 1 / 



Size of establishment 
(Number of employees) 


Cumulative percentages 


Total 

Port-au-Prince 

Provincial 

towns 

Estab¬ 

lish¬ 

ments 

Em¬ 

ploy¬ 

ees 

Estab¬ 

lish¬ 

ments 

Em¬ 

ploy¬ 

ees 

Estab¬ 

lish¬ 

ments 

Em¬ 

ploy¬ 

ees 


22.9 

4.0 

22.4 

3.6 

23.8 

4.8 

2..... 

43.4 

11.2 

42.1 

10.0 

45.6 

13.6 

3............. 

57.5 

18.6 

54.3 

16.0 

62.7 

23.8 

4»e»ooo»..o»ee«®.°e.® 

67.5 

25.6 

64.2 

22.4 

73.0 

32.1 


72.2 

29.6 

69.7 

26.8 

76.2 

35.3 

6 0 .... 

77.4 

35.1 

76.2 

33.2 

79.4 

39.2 

7... 

80.2 

38.6 

78.4 

35.6 

83.3 

44.7 

8 - 10.......... 

87.9 

50.6 

87.3 

48.6 

88.9 

54.8 

11 - 15... 

93.3 

62.9 

93.3 

61.2 

93.3 

66.2 

-L *" 23 oo©»ocooo©co©o©oo 

97.5 

77.6 

97.4 

74.9 

97.6 

83.2 


99.3 

87.2 

99.0 

83.9 

99.6 

93.9 

50 — 99 o.o..oe. 00 * .. 0... 

99.7 

92.3 

99.5 

88.6 

100.0 

100.0 

100 *"100 ©®«©o«e»*oo©«©*o©o 

100.0 

100.0 

100.0 

100.0 

100.0 

100.0 

090000090*99000966 

100.0 

100.0 

100.0 

100.0 

100.0 

100.0 


1/ Includes regular and administrative employees only. 




















- 24 - 


Table 4 

Distribution of Employees, by Earnings, in Private Employment 

Port-au-Prince 

(Based on a special survey, April 15, 1950) 1/ 


Earnings per 
month (0) 

All 

Weekly employees 

Monthly employees 

Number 

Average(0) 

Number 

Average(0) 

Number 

Average(0) 

Less than 105.. 

882 

87 

662 

82 

220 

100 

Less than 110.. 

1,014 

90 

718 

84 

296 

102 

105-150........ 

636 

122 

133 

116 

503 

124 

110-150. 

504 

126 

77 

121 

427 

127 

151-300. 

638 

208 

192 

192 

448 

215 

301-500. 

255 

377 

69 

325 

186 

396 

501 and over... 

199 

824 

— 

— 

199 

824 

Less than 110.. 

1,014 

90 

718 

84 

296 

102 

110-150. 

504 

126 

77 

121 

427 

127 

151-500. 

893 

256 

261 

227 

632 

268 

501 and over..• 

199 

824 

— 

— 

199 

824 

All. 

2,610 

210 

1,056 

122 

1,554 

269 


1/ Includes regular and administrative employees only. 












- 25 - 


Table 5 

Distribution of Employees, by Earnings, in Private Employment 

Provincial Towns 

(Based on a special survey, April 15, 1950) 1/ 


Earnings per 
month (^Q 

All 


Weekly employees 

Monthly employees 

Number 

Average($) 

Number 

Average(0) 

Number 

Average($) 

Less than 105.* 

639 

93 

257 

82 

382 

100 

Less than 110.. 

738 

95 

270 

83 

468 

101 

105-150........ 

504 

120 

55 

116 

449 

120 

110—150........ 

405 

123 

42 

119 

363 

123 

151-300..... 0.0 

273 

208 

44 

179 

229 

213 

301-500........ 

100 

399 

5 

305 

95 

404 

501 and over... 

27 

716 

•— 

— 

27 

716 

Less than 110.. 

73 S 

95 

270 

83 

468 

101 

00066004 

405 

123 

42 

119 

363 

123 

151-500........ 

373 

259 

49 

192 

324 

269 

501 and over... 

27 

716 

—_ 

— 

27 

716 

AH & 0 & c 0 000 

1,543 

153 

361 

102 

1,182 

168 


1/ Includes regular and administrative employees only. 






- 26 - 


Table 6 

Distribution of Employees, by Earnings, in Private Employment 
Port-au-Prince and Provincial Tornis 
(Based on a special survey, April 15, 1950) 1/ 


Earnings per 
month (0) 

All 

Weekly employees 

Monthly 

employees 

Number 

Average ( 0 ) 

Number 

Average ( 0 ) 

Number 

Average(0) 

Less than 105.• 

1,521 

89 

919 

82 

602 

100 

Less than 110*. 

1,752 

92 

988 

84 

764 

102 

105-150. 

1,140 

121 

188 

116 

952 

122 

110-150. 

909 

125 

119 

120 

790 

125 

151-300. 

911 

208 

236 

190 

675 

214 

301-500 . 

355 

383 

74 

324 

281 

399 

501 and over... 

226 

809 

— 

—— 

226 

809 

Less than 110.. 

1,752 

92 

988 

84 

764 

102 

110-150. 

909 

125 

119 

120 

790 

125 

151-500. 

1,266 

257 

310 

222 

956 

268 

501 and over. • • 

226 

809 

—— 

— 

226 

809 

All. 

4,153 

188 

1,417 

117 

2,736 

225 


1/ Includes regular and administrative employees only* 













- 27 - 


Earnings were nearly twice as high, on the average, for the 
monthly as for the weekly employees: 


Average earnings 
per month 


Monthly employees... 0225 

¥e e kly e mpl oy e e s. 0117 


There were altogether 226 employees covered by the survey whose 
earnings were 0501 or more per month. Their average earnings were 
determined from a special tabulation prepared for 162 such employees 
whose actual monthly earnings had been reported. The results are 
shown in Appendix table 4. 

Sickness Absenteeism 

The survey of private employment included an inquiry as to the 
number of employees who had had any sickness absenteeism of 1 day or 
more at any time during the 12 months preceding the day of survey, and 
the duration of such absenteeism. This inquiry did not distinguish 
between work-connected and non-work-connected cases, and it covers both. 

Of the 4,240 employees in the establishments covered by the 
survey, 4,185 (3,054 males, 1,130 females, and 1 unknown) were in 
establishments for which the occurrence of sickness absenteeism was 
reported. 

The distribution of cases by duration is shown for all surveyed 
establishments, for those in Port-au-Prince and for those in the 
provincial towns in table 7. The results may be summarized as follows: 



Total 

Port-au- 

Prince 

Provincial 

towns 

Employees with absenteeism 

ijumbsr o©oo©o©oo©o©oooooo© 

888 

453 

435 

Percent. . .. 

21 

17 

28 

Total cases........... o ..... 

892 

454 

438 

Total days of absenteeism 

M XIH1TTIUTI1 3 ! oooooeooooooooo 

12,416 

6,591 

5,825 


16,126 

8,446 

7,680 

Days per case 

iviiniimim $/ o©ooo©©©oooooo® 

14 

15 

13 

Maximum j>/„.............. 

18 

18.6 

18 

Days per employee 

Minimum© ooo®ooo©#©o©©©©©© 

3.0 

2.5 

3.8 

Maximumo ©o©©o©©o©©©o©oe®o 

3.9 

3o2 

5*0 


j>/ The range results from using 100 and 365 days as the minimum and 
maximum durations, respectively, for 14 cases reported as having 
lasted 100 days or more. 














- 28 - 


Table 7 

Sickness Absenteeism in Private Employment 
(Based on a special survey, April 15, 1950) 


Duration of absenteeism 
(days) 

Total 

Port-au- 

Prince 

Provincial 

towns 

Cases 

Days 

Cases 

Days 

Cases 

Days 

1 - 4. 

309 

773 

134 

335 

175 

438 

5 - 9. 

222 

1,554 

99 

693 

123 

861 

10-14. 

109 

1,308 

90 

1,080 

19 

228 

15-19. 

106 

1,802 

58 

986 

48 

816 

20 - 24. 

29 

638 

15 

330 

14 

308 

25 - 29. 

13 

351 

5 

135 

8 

216 

30-34. 

31 

992 

16 

512 

15 

480 

35 - 39. 

6 

222 

3 

111 

3 

111 

40 — 44* ».»«•»•••••••••••••»«••• 

1 

42 

1 

42 

— 

— 

45 - 49. 

16 

752 

6 

282 

10 

470 

50 - 54. 

.2 

104 

1 

52 

1 

52 

55 - 59. 

1 

57 

1 

57 


— 

60 - 64. 

19 

1,178 

12 

744 

7 

434 

65 - 69. 

1 

67 

—— 


1 

67 

70 - 74. 

1 

72 

1 

72 



75 - 79. 

—_ 




__ 

_ .« 

80 - 84. 

oc £a 

— 

— 

— 

— 

■— 

— 

90-94. 

12 

1,104 

5 

460 

7 

644 

95 - 99. 







100 or more.. 

14 


7 


7 


Minimum 1/. 


1,400 


700 


700 

Maximum "• /. 


5,110 


2,555 


2,555 

All durations.. 

892 


454 


438 


Minimum 1/. 


12,416 


6,591 


5,825 

Maximum 1/. 


16,126 


8,446 


7,680 


1/ Using 100 and 365 days as the minimum and maximum, respectively, for the 
cases lasting 100 days or more. For all other durations, using midpoints 
of the group durations in which the data are available. 

































- 29 - 


The reported frequency of sickness absenteeism in a 12-month 
period was much higher in the provincial towns (28 percent of the 
surveyed employees) than in Port-au-Prince (17 percent). 

There were altogether 892 cases of sickness absenteeism 
reported by 888 persons among the 4,135 in establishments for which 
sickness absenteeism was recorded—almost exactly one case per person 
reporting any such absenteeism. The 892 cases involved between 12,416 
and 16,126 days of absenteeism,6/ 

• In order to make the dhta more useful for the purposes of this 
study, they were regrouped, as to duration of disability, by inter¬ 
polation, The results are shown in table 8, 

As usually- found in sickness surveys, most of the cases were 
of relatively short duration. Thirty-five percent lasted 4 days or 
less, 50 percent 7 days or less, 72 percent 2 weeks or less, 86 percent 
3 weeks or less, and 89 percent 30 days or less. Cases lasting 1 month 
or more accounted for only 11 percent of the total cases. 

The short-term, cases, though relatively frequent, do not cause 
a large proportion of the total days of absenteeism. For example, cases 
lasting one week or less accounted for 50 percent of all cases but they 
contributed only 11 percent of all the days of absenteeism. Conversely, 
the relatively few long-continued cases (11 percent lasting 1 month or 
longer) accounted for a large proportion (54 percent) of all the days. 

The average duration per case was 14-13 days. In relation to 
all the surveyed employees, the days of sickness absenteeism equaled 
3.0-3,9 per employee. The corresponding figures were somev/hat lower 
for Port-au-Prince (2.5-3<>2) and substantially higher for the 
provincial towns (3,8-5.0), 

These figures are much lower than the corresponding figures’ 
usually found, elsewhere, on the incidence of disability among gainfully 
employed persons. Lacking many details, it is not possible to determine 
whether the figures derived from this survey correctly reflect a low 
incidence of sickness absenteeism among the surveyed employees, whether 
they are only apparently low by reason of age distribution, or whether 
they reflect under-reporting of absenteeism. It is possible that if 
they are low because of under-reporting, this results in part from 
failure to obtain reports for those who were sick and absent from work 
on the day of survey. 


6/ See footnote 5. 





- 30 - 


Table 8 

Sickness Absenteeism in Private Employment 
(Data regrouped by interpolation) 


Duration 

of 

incapacity 
(days and 
months) 


Number of cases 



Days 


Number 


Cumulative 

Number 

Per¬ 

cent 

Cumulative 

Per¬ 

cent 

Number 

Per¬ 

cent 

Number 

Per¬ 

cent 

1 day..... 

97 

10.9 

97 

10.9 

97 

0.7 

97 

0.7 

2 days.... 

78 

8.7 

175 

19.6 

156 

1.1 

253 

1.8 

3 « .... 

69 

7.7 

244 

27.4 

207 

1.4 

460 

3.2 

4 w .... 

64 

7.2 

308 

34.5 

256 

1.8 

716 

5.0 

5 » .... 

50 

5.6 

358 

40.1 

250 

1.7 

966 

6.7 

6 » .... 

42 

4.7 

400 

44.8 

252 

1.8 

1,218 

8.5 

7 « .... 

49 

5.5 

449 

50.3 

343 

2.4 

1,561 

10.9 

8-14 “ _ 

191 

21.4 

640 

71.7 

1,966 

13.7 

3,527 

24.6 

15-21 » .... 

127 

14.2 

767 

86.0 

2,318 

16.2 

5,845 

40.8 

22-28 « .... 

17 

1.9 

784 

87.9 

461 

3.2 

6,306 

44.0 

29-30 '• .... 

9 

1.0 

793 

88.9 

264 

1.8 

6,570 

45.9 

1-2 months.... 

55 

6.2 

848 

95.1 

2,169 

15.1 

8,739 

61.0 

2-3 months.... 

21 

2.4 

869 

97.4 

1,443 

10.1 

10,182 

71.1 

3 months or 









more 1/.. 

23 

2.6 

892 

100.0 

4,140 

28.9 

14,322 

100.0 

All durations 

892 

100 <03 

892 

100.0 

14,322 

100.0 

14,322 

100.0 


1/ For the purposes of this redistribution, the cases previously shown with 
duration of 100 or more days, which are here shown with duration of 3 
months or more, were each assigned 180 days of incapacity. Regrouping was 
guided by a special tabulation of 315 cases with known actual duration. 















- 31 - 


In evaluating the figures, considerable allowance must be made 
for a strong tendency in Haiti for workers to stay on the job despite 
illness„ There is no doubt that this tendency exists because of great 
insecurity of employment in a labor market which has much unemployment 
and a large pool of persons actually and potentially seeking wage and 
salary employment,. 


Private Employment in Some Large 

Agricultural Establishments 

The survey summarized in the preceding pages covered only urban 
employments. It did not contribute toward meeting the deficiency of 
data on agricultural employment. 

No new data were compiled concerning small or medium-size farms 
or plantations. Special field visits were made to a few large 
agricultural establishments, and data concerning wages, turnover, 
accidents, etc. were obtained from the managements. The information 
will be referred to later. In addition, special tabulations were 
prepared by the Bureau of Labor on employment in six large agricultural 
establishments. Although these figures are fragmentary, they are 
recorded here because they have been found useful in the analysis of 
agricultural coverage. Five of the six are sisal plantations| the sixth 
is a lumbering establishment. The data apply (variously) to periods 
between October 1940 and June 1950. 

The variations in employment in these six establishments are 
summarized in table 9, in terms of average, maximum and minimum monthly 
numbers of employees. Earnings are shown -in terms of average weekly 
wages only, because there was relatively little monthly variation. 

Public Employment 

As in the case of private employment, the Bureau of Labor under¬ 
took to compile information concerning public employment in Haiti. 

Three surveys were made, obtaining progressively more complete data. 

First Survey 

In this survey, the Bureau of Labor compiled information for a 
sample of offices in the 12 Ministries of the Haitian Government in 
Port-au-Prince. It prepared tabulations showing the number of 
employees, their marital status, whether employed on a monthly or 
weekly basis, and their salaries. 

There were 701 employees covered by the survey in these 12 
Ministries (Appendix table 5). As appears in table 10, four-fifths 
(81«3 percent) were males$ nearly 44 percent were married, 9 percent 
were placd', 46 percent lived alone, and 2 percent were not reported as 
to marital status ; and nearly all (95 percent) were employed on a 
monthly basis. 






- 32 - 


Table 9 

Employment and Earnings in Six Agricultural Establishments 


Establishment 


Employment 1/ 
Average Maximum Minimum 


Average 

weekly 

wages 

(« 


Period 


Sisal 
1 ..., 
2 . ... 

3 .. .. 

4.. .. 

5.. .. 

I&gfoer 

6 .. .. 


6,306 

2,093 

745 

133 

1,809 


354 


6,783 

2,459 

780 

228 

2,215 


391 


5,936 

1,517 

704 

68 

1,289 


319 


26o 7 
14.0 
22.9 
32.2 
21.7 


35.9 


Oct. *49-June '50 
Oct. ’49-June '50 
Oct. ’49-Mar. ’50 
Apr. '50-June '50 
Oct. '49-Mar. *50 


Oct. '49-Mar. '50 


1/ Covers salaried employees, wage earners and "piece 11 or "contract" 
farm laborers ("ouvriers et travailleurs"). 















33 


Table 10 

Some Characteristics of Employees in Public Employment? 1950 
(First Survey of Public Employment) 


Total employees 


o oooooooooooeo 


S6X oooooeoooeoooooo et>*©oo®ooo©©ooo *ooo©oo© 

Male © © o © © O© ©OOOOOOO©©® O © © 8 0 ©®©® 000 ®© 0 ©® 0 ©Q 
Female oo©o®oo©o©Oo©oe©eo®o®oo©oo©ooo©o©o®o 

By marital status %o © ® © ©oQ©®®o©o©®®©©©o©©o©®a© 

Marriedo®©o©ocoe©©®©o©®o©*o©®®©«oc>©©e®©®®o 
PlaceOO©O®OOO©O©OO®OO©OOOOO 0 OO®©©O®©OOOO®O 

Living aloneo©ooo»©ooooo0®oooo®9oo®®®«o©o« 
Not reportedooo©©oo©©«©ooeo©o©©9ooo©©o©©©o 

By employment•o©oooo©©o©oo©oo©©oo©©©oeo©©©o©o 
Monthly o©©o©©©©©o©o®©©©«o©©o*©©o©o©©o©®©o© 
"Weeklyoooooo©©©o®®o®®©®«®©®*®©oo©o©©ooo©o© 
Not specified© © ©©©oo®®®©®®©®©©©®©®*©©®©©#© 


Number 

Percent 

701 

100.0 

701 

100 o 0 

570 

81,3 

131 

18o7 

701 

100,0 

306 

43° 7 

62 

8*8 

321 

45.8 

12 

1.7 

701 

100,0 

664 

94.7 

22 

3.1 

15 

2.1 












—.34 — 


Earnings data wejpe provided for 653 employees "who were employed 
on a monthly (salary) basis. Their distribution by earnings is 
sumiiari2e& in table 11, in classes selected with respect to monthly 
amounts pertinent to the proposed social insurance contribution rates. 

The average earnings may be restated as follows: 


Per month Per year 


All employees.........o.•... 

$314 

$62.80 

$3,768 

$753.60 

Employees with not more than 
$500 per month............ 

$237 

$47.40 

$2,844 

$568.80 

All employees, excluding 
earnings in excess of 
$500 per month.. 

$293 

$58.50 

$3,511 

$702.25 


Second Survey 

The Bureau of Labor then made a second study of public employment, 
by analysis of the Budget for 1950-51. The tabulations were limited 
to employees with earnings of not more than $500 per month, the maximum 
limit contemplated at that time for coverage and for contributions in 
the social insurances. The data apply to a total of 5,383 employees, 
but the figures are not altogether useful because they do not cover 
employees with earnings of $301-$5OO in four of the Ministries. 

In those offices for which the data are complete, there were 
4,799 employees (Appendix table 6), divided as follows: 

Monthly earnings Number 

$300 and less.4,181 

(Zf301-jzf500.. 618 

The distribution of these employees, according to Ministry of 
employment, by geographical location is shown in Appendix table 7. 

The total payrolls for these employees in the surveyed Ministries—by 
geographical de’partement and by earnings level—are shown in table 12 . 
They yield the following: 


Monthly earnings class 

$300 and less.......... 

$301-$500.OOO.O..00.00. 

$500 and less...„...... 


Average earnings 


Per month 

Per year 

$193 

$39 

$2,326 

$465 

415 

83 

4,980 

996 

221 

44 

2,652 

530 
















- 35 


Table 11 


Distribution of Monthly Employees, by Earnings, 
in Public Employment: 1950 


(First Survey of Public Employment) 


Earnings per month ($) 


Number of Monthly 

employees average ($) 


Less than 105. 
Less than 110„ 


eoooooooooooooooooooeoeo 


oooooo©oooc» 9 d©ooeo«o©ooo 


105 - 150. 

no - 150 . 

151 - 300 o 
301 - 500. 


O <5 0® O O © OOOOOO © 0090 © © © • © O 0090 


0090000900999900000099900900 


oooooeooo 


0000090090990000000090090994 


More than 500 


OO 00009 00900 ©0009900© O 900 


Less than 110 00 . 00 . 0 ..oo.ooo.oo.. 000.0 

110 ““ 150 o 0 0 0 . 0 . 000000000.00000 oo« «eoo 

151 ” 500 sooooooa.o. 00.00900000.0. 0.0 0 

More than 500 oo .oc»©oooo©.o»ooooo©.ooo 

500 and leSS .©©ooooeeoo©o©ooo»»oO 

More than 500 © 0 . 00 . 00.0 ««©oo©oooo 


All earnings 


900000 0990 e O O O © e 


18 

31 

104 

91 

275 

118 

138 

31 

91 

393 

138 

515 

138 

653 


1/100 

103 

127 

129 

226 

380 

1/600 


103 

129 

272 

1/600 

237 

600 

314 




1/ Assumed average© 








- 36 - 


Table 12 

Employees and Earnings in Public Employment: 1950-51 
(Second Survey of Public Employment) 


Departe- 

ments 

Number of 
employees 1/ 

Payrolls 1/ 


Total 

Monthly 

salary 

Total 

Monthly salary 

$300 

and 

less 

1 

H O 

O O 

$300 and 
less 

$301-500 

North..oo.o. 

646 

627 

19 

0126,317.50 

$118,017.50 

$ 8 , 300.00 

Northwest..„ 

203 

194 

9 

39,975.00 

36,150.00 

3,825.00 

Artibonite.. 

566 

537 

29 

115,860.00 

103,985.00 

11,375.00 

Ylestf 00009900 

2,728 

2,190 

538 

653 , 530.00 

431,230.00 

222,300.00 

Soiltifl O €» 0 O o O O 

656 

633 

23 

126,378.50 

116,503.50 

9,875.00 

Total.* o„ 

4,799 

4,181 

618 

1,062,061.00 

805,886.00 

256,175.00 


1/ Potentially subject to compulsory insurance if the limit is fixed at 
$500 per months excludes employees earning more than $500 per month,, 








Thind Survey 


Finally, the Bureau of Labor made a third survey of public 
employment, covering all 12 Ministries for the fiscal years 1949-51 
and all salary levels, and dividing the data so as to give figures 
separately for Port-au-Prince and the #1016 country. This is the most 
comprehensive of the three surveys. The results are recorded in 
Appendix tables 8 (all Haiti) and 9 (Port-au-Prince). 

The survey covers a total of 6,656 public employees throughout 
the country, with 3,088 of them in Port-au-Prince. Their distributions 
by earning class may be summarized as follows: 


Average annual 

Employees earnings 


Monthly earnings class 

Haiti 

Port-au- 

Prince 

Haiti 

Port-an 

Prince 

$300 and less........ 0 

4,893 

1,892 

$445 

$478 

^301-^500 .ooo.ooos.ooe 

893 

716 

942 

994 

$501 and more......... 

870 

480 

2,005 

2,038 


6,656 

3,088 

716 

840 


As expected, the average earnings were higher in Port-au-Prince 
($840) than in the country as a whole ($716). The figure for the 
capital city is substantially higher than the figure derived from the 
first survey ($754) which was restricted to a sample of offices and 
applied to early 1950. 

Sickness Absenteeism 

A questionnaire canvass was made by the Bureau of Labor in six 
of the Government offices that were being surveyed in April 1950 (first 
survey of public employment) for information on employment, family 
composition, salaries and wages, etc. These six offices had 560 
employees—presumably representative of all public employees in Port- 
au-Prince o 

The reported sickness absenteeism in the 12 months preceding the 
day of the survey is summarized in table 13. The results may be 
summarized as follows: 


Cases of sickness absenteeism............ 73 

Cases per 100 employees.e.o...e.oo.ea..oe 13 
Days of absenteeism (total).oo.oooo.«oooo 1,178 
Days per case....... 00000 . 0 .16 

Days per employee (annual)............... 2.1 














- 38 - 


Table 13 

Sickness Absenteeism Among Public Employees 

Cases and days of sickness absenteeism in 
preceding 12 months among 560 employees 
in 6 government offices in Port-au-Prince 

(April 1950) 


Duration of absenteeism 
(days) 

Number of 

cases 

Days of 
absenteeism 

1 - 3 ........ 

22 

55 

4- 7 .... 

13 

78 

S - 11. ... 

7 

70 

12 - 15. ... 

17 

238 

16-19 _......................... 

— 

— 

20 - 23....... . 

3 

66 

24 - 27 ... 

— 


23 - 31... .... 

4 

120 

32 - 35.. ... 

— 

_ 

36 - 39...... .... 

—— 

—— 

40 — 43 0. 0. a .o... ..o«. ......... 00. .« 

2 

84 

44 - 47 .a .. a ... 0 .......... c ... 0 a 



48 - 51. .............. a ... . ..... . . . . 



>2 — 55o ... a .. a . a ..... a . a .......... a 

— 

—— 

56 •"* 59 ©OOOOOOOOOOOCOOOOOOOOOOOOOO©# 

— 

—— 

™ 3 nooocooeoooottooo ©••®ooe*©oo© 

1 

62 

90 ....a. ........ ....... ...a.... 

3 

270 

O 0 0 o 0 0 © e 0 • e 0 0 o 0 0 © 0 0 0 ©oooeooo© 

13 3 ©©OOOOOOOOOOOeoOOOOOOOOOOOOO© 

1 

135 

diii'S'tions©©©0000000000 00 00 000 000 

73 

1,178 





















“ 39 ” 

The number of eases and of days per employee are seemingly low. 
Again, as in respect to private employees, the interpretation of the 
figures is somewhat uncertain. 


- 40 - 


CHAPTER IV 

Present Resources for Medical and Hospital Care 

The insurance systems proposed by the Social Insurance Law of 
October 1949 propose to furnish medical as well as cash (wage-loss) 
benefits,. This is true for both work-accident insurance and sickness 
and maternity insurance. It was therefore evident from the beginning 
of this study that the availability of adequate medical and hospital 
resources would be vital to the successful operation of a social 
insurance program. 

Preliminary study indicated that Haiti’s resources for medical 
and hospital care are small and very unevenly distributed geographically 
and in relation to population. It was essential to determine their 
capacity for providing the service benefits that would be promised by 
the insurance systems, but comprehensive information about them was 
not available and had to be compiled. The main sources of information 
were the Department of Public Health, a canvass of public hospitals and 
clinics mad$ by the Bureau of Labor, conferences with medical leaders, 
visits to institutions, and miscellaneous published and unpublished 
documents. 


Physicians 

The Department of Public Health advises that, as of March 1951, 
Maiti has a total of 297 physicians, equivalent to about 1 per 10,500 
persons in the total population. Of these, 180 are in various salaried 
employments and 117 are exclusively in private practice, as follows: 


In salaried employments 

180 

Department of Public Health 

142 

SCISP 

13 

Arny 

18 

Industry 

7 

In private practice (only) 

HZ 1/ 

Total 

22Z 1/ 


Most of the physicians who have salaried employment also engage 
in the private practice of medicine. Thus, the nui&er in private 
practice is much larger than would appear from this tabulation. Those 
in private practice (117) plus those employed by industry (7) equal a 


1/ These figures are probably somewhat too high because they do not 
allow for partial or total retirement from active private practice 
or for absence from the country. 








- 41 - 


total of 124, equivalent to about 1 per 25,000 persons 0 The total 
number of physicians available for medical service to the general 
population is probably about 249, including the folio-wings 

Employed in hospitals and 


health centers 125 2j 

Employed in industry 7 

In private practice 117 21 

Total 249 2l 


This total—which is too high but by an undetermined number—is 
equivalent to about 1 physician per 12,000 persons„ One per 2,000 
persons would probably be the minimum number of physicians needed in 
Haiti to provide anything approaching adequate medical care of modern 
standards. 

The geographical distribution of physicians is very uneven 
throughout Haiti 0 As of March 1951, it was as follows: 


Ddpartements 

Number 

of 

physicians 

Persons 

per 

physician 

No irbll 00* *00000600000 

29 

18,627 

Northwest 0 •„ 0 •»,.. 0 

9 

18,705 

Artibonite. 0 ° o«« e » s 

27 

21,062 

We St 000000060000000 

212 

5,163 

South 00000000*00000 

20 

3,701 

Total;o o o o„ 

297 

10,478 


The ratios to population range from 1 physician per 3,700 
persons in the South to 1 per 21,000 in the Artibonite*, Indeed, the 
distribution is even more uneven than these figures would indicate„ 
Practically all of the physicians live in the larger cities and towns, 
and practice primarily among the urban population in the immediate 
vicinity and the rural population living nearby 0 


g/ Derived by reducing the number reported in the employ of the 

Department of Public Health (142) to 100, to allow for those engaged 
in administration, specialized public health work, etc c to 

• avoid duplication with the total number (117) counted in private 
practiceo 

2/ These figures are probably somewhat too high because they do not 
allow for partial or total reuirement from active private practice 
or for absence from the country*, 






- 42 - 


Only a few practitioners are located in the smaller towns$ 
practically none are in the villages, and of course none are in the 
rural areas—which have a large proportion of the total population,. 

An urban location of physicians is quite customary, but it is 
unusually important for Haiti because so much of the country is 
mountainous and so much of it is without good roads or means of 
transportation essential to enable rural people to have ready access 
to medical care. 

The distribution of physicians is more meaningful when inspected 
with reference to geographical subdivisions smaller than ddpartements. 
Appendix table 10 shows the location of all physicians by localities 
(as well as d^partements), and Appendix table 11 shows the location of 
118 physicians who, as of April 1950, were employed (full-time or 
part-time) in hospitals and health centerso 

The physicians are heavily concentrated in Port-au-Prince and 
its immediate environs, and in those provincial towns which have public 
hospitals, Since the medical benefits of the social insurance programs 
would have to be provided mainly through the hospitals and their 
clinics for ambulatory patients, the distribution of physicians must 
be seen not only by ddpartements but also by reference to the location 
of the hospitals, A special tabulation was prepared to show the 
location of the 241 physicians engaged in serving the general population 
(as of April 1950), This tabulation (table 14) excludes the physicians 
who were engaged exclusively in public health administration and in 
special public health programs or who were in the Garde d ! Haiti, 

The 241 physicians engaged in clinical practice are equivalent 
to about 1 per 13,000 persons in the total population—about one-sixth 
the number that might be considered the minimum necessary for essential 
medical care in Haiti, By ddpartements, the ratios range from 1 per 
6,200 in the West (including Port-au-Prince) to 1 per 53,000 in the 
South, By hospital districts, the ratio is as low as about 1 physician 
per 3,000 in the Port-au-Prince district and as high as 1 per 71,000 
in the Petit Goave district. Most of the ratios would be still more 
adverse if the numbers of physicians could be deflated—as they should 
be—for physicians who are registered but are not actually engaged in 
the practice of medicine or are abroad. 

Of the 299 physicians in Haiti in April 1950, 86 were reported 
to be engaged wholly or mainly in a specialty of medicine; in 
obstetrics and gynecology, 23$ in general surgery, 20$ in pediatrics, 

11$ and in other specialties, 32, Their geographical distribution is 
shown in Appendix table 12, 


- 43 - 


Table 14 

Geographical Distribution of Physicians Engaged 
in Clinical Practice 1/ 

(April 1950) 


Departement or 
hospital district 

Number of 
physicians 

Persons per 
physician 

Departement 


22 

24,554 

I'i OI**fc]fl'W© © © o © © o o e> o o o o o • • eo ooo 

5 

33,669 

Art/ibonits ooa&oooooeooeoooco© 

23 

24,725 

West.. .. . c 

177 

6,184 

ilOll'bhl ooocooooooeoooooooeoeeoo 

14 

52,869 


241 

12,913 

Hospital district 

CaPrHaitienc ®oeoooooceooeo»«o 

22 

24,554 

PO}T*fc'~ 1 bL0®“PclILX o oooeeoo«c o o c © e* © e 

5 

33,669 

Gonaives* o©ooooooe©ot>eooooooo 

9 

20,181 

BlUClX© o#®oe©®o©o«©©oo©o©o©©o© 

7 

20,101 


9 

25,170 

Belladere © «©o©ooo©o©o©eco«©o© 

3 

51,949 

Port-au-Prince o©o©o©oo©»o©oo© 

163 

2,951 

Jacmel ooo®eooooooe«;c®®ooo®ooa 

7 

35,201 

GOaVS eoo©oo«ce«oe©oo900 

5 

70,665 

J^remie eoso®esaeo o.a eoooooo®o® 

5 

44,452 

Les CayeSo »oooo®oooo®»ooe®®oo 

8 

46,968 

A±lo ooooo®oooooo«o«ooooO 

241 

12,913 


iJ Includes physicians employed in public hospitals, clinics, 
dispensaries, health centers, etc®, and those in private 
practice and in industry. Excludes physicians in public 
health administration, in special public health programs, 
and in the Garde d 9 Haiti e 












- 44 - 


The geographical concentration of physicians is especially heavy 
in and around Port-au-Prince<, Of the total of 299 physicians (April 
1950), 194 or 65 percent were in the capital city and its suburbs 
(Port-au-Prince and P^tionville) which have only about 5 percent of 
the total population (152,400 of a total of 3,112,000, according to 
the census of August 1950) 0 Of the 241 counted as engaged in clinical 
practice, 163 or 68 percent were located in this area* Thus, the 
immediate capital area has about 1 physician per 800 persons» These 
physicians serve not only the capital but also the surrounding area— 
a total population of about 500,000, and in some measure the whole 
country because of cases referred to Port-au-Prince from other places 0 

The rest of the country has about 105 physicians of all kinds„ 
Exclusive of those in employments which limit their availability to the 
general public (3CISP, 8; and Army, 11) there are about 86 outside the 
capital and its immediate environs, equivalent to about 1 per 34,400 
personso Of these 86, only 78 are estimated to be engaged in clinical 
practiceo 

Most of the physicians were trained in the national medical 
school in Port-au-Prince* Many (the exact number is not available) 
have had education and training in other countries 0 The medical school 
has been graduating about 20 students a year* It recently expanded 
its student bocfy and is prepared to graduate about 40-50 per year* 

No comprehensive or altogether reliable data are available on 
physicians’ incomes. The Department of Public Health estimates that 
average net income of all physicians in Haiti is about $2,400 per year— 
about $1,200 from public employment and an equal amount from private 
practiceo Some private practitioners who were consulted on this point 
estimate that the average net income of general practitioners (from all 
sources) is about $2,400 a year, of specialists about $4,200 a year, 
and of all physicians (assuming 4 general practitioners per specialist) 
about $2,760 a year* 

According to the Budget for Haiti for 1950-51, physicians 
employed in the Department of Public Health receive on the average 
$1,567 a year 0 For the clinical practitioners, as distinguished from 
administrators, this is salary for a little more than half-time 
service—5 hours a day c 

It may be estimated that total gross income of all physicians 
in Haiti is about $900,000 a year;-and total net income about $750,000 
a year* The gross figure is equivalent to about $0*30 per capita for 
all of Haiti* If regarded as paid, in the main, by one-half the 
population, the total is equivalent to $0*60 per capita for these 
people; and if treated as paid principally by one-third of the population, 
it amounts to $0*90 per capita for them* Of the dollar amount, about 
one-half is spent through public (Government tax) funds, and about 



- 45 - 


one-half through private £$$ payments. In addition, it is reported 
that a substantial amount (some estimates are as high as $200,000 to 
$500,000 a year) is spent for all kinds of medical care by middle and 
upper income classes for services obtained outside Haiti. 

The fee charged for an office visit is generally $l-$2— 
occasionally $3; for home calls $2-$5. No quantitative information 
is available on the extent to which fees are actually collected. 

No reliable data are available on the physicians’ work-loads. 

As noted earlier, those who hold salaried positions in the hospitals 
and health centers quite generally engage in private practice outside 
the regular hours of their (part-time) salaried positions. Both they 
and the physicians who are exclusively in private practice are reported 
to be generally occupied for substantially less than their full or 
maximum (practical) capacity. Informal estimates, furnished by officers 
of the Department of Public Health and by private practitioners, agree 
that physicians have unused time equal, on the average, to at least 
25 percent and more probably 33-1/3 percent of full-time capacity. 

In addition, it is a cornnon opinion among physicians that the supply 
of physicians in Haiti would be quickly augmented by the 25-50 who are 
abroad if their opportunities for practice in Haiti were improved. 


Hospitals. Clinics and Dispensaries 


The hospitals of Haiti include the following (as of March 1951 )i 


'oooooooooooooooeoooo 


OOOOOOOOOOOOOOOOOOO 


Public 4 / (Department of Public Health) 
General hospitals. 

Maternity hospital. 

Tuberculosis sanatorium.............. 

Hospital for psychopathic patients 
Health centersoo».ooooooooeooooooo».o 
Dispensaries - “standard”............ 

Dispensaries - “non-standard”« 


Private 

Hospitals and clinics 


oooooooo 


ooo©ooe©®e>oooo«o 


Number 

11 

1 

1 

1 

4 

43 

98 


.Beds 

1,476 

100 

100 


77 


Thus, the hospital and related facilities are, in the main, those 
owned and operated by the Government. They employ a total of 1,010 
persons. 


4/ This tabulation excludes the HSpital Militaire (Garde d*Haiti) 
which has about 80 beds, and the 9 asylums for the indigent with 
300-1,QOO re sidents. 

^ Gonstruction started., but not yet completed. 









- 46 - 


All of the 1,653 beds in general and maternity hospitals, public 
and private, are equivalent to about one bed per 1,900 persons* If 
they were distributed throughout the country in reasonably uniform 
relation to population they would be about one-fifth or one-fourth the 
minimum number (1 per 400 or 500 persons) that could be conceived as 
sufficient for care of the population* 

The location of the 11 public general hospitals and the one 
public maternity hospital, and the distribution of their beds among 
public wards and private and serai-private rooms, are shown in table 15* 
The location of the public hospitals by d^parteraents and by hospital 
districts, and the ratios of beds to population are shown in table 16 0 

Thus, for the country as a whole there were 1,975 persons per 
bed in the public hospitals (general and maternity)* But this average 
conceals a very wide range—from 1,300 persons per bed in the 
Departement of the West to 3,800 per bed in the Ddpartement of the 
Northwest, and from 780 to 5,200 persons per bed in the various 
hospital districts* 

The private hospitals and clinics have a total of about 77 beds* 
Since they are all located in Port-au-Prince, they increase the number 
of beds serving the capital area to a total of 694, with about 700 
persons per bed in this hospital district* 

The public hospitals are supplemented by dispensaries, which 
are now widely distributed throughout the country* According to the 
latest available information, there are 141, of which 43 are classified 
as ‘‘standard 11 and 98 as “non-standardTheir distribution by 
departements and by hospital districts is shown in table 17* It is 
generally agreed that, for the most part, they are quite inadequately 
staffed, equipped and supplied* 

Service in the public hospitals and dispensaries is generally 
furnished without charge, though those who can afford to do so are 
expected to pay nominal fees* In the hospitals, the usual charge for 
a private room is $2 ( 010 ) per day, and for a semi-private room 
$1 ($5) per day* The charges for a consultation or clinic visit range 
from about $0*05 to $1*00 ($0*20-05*00)* 

In 1947, the last year for which detailed data are available, 
the 11 general public hospitals are reported to have had a total of 
28,377 admissionso6/ The average daily census of in-patients in that 
year was 1,108, and it was substantially uniform throughout the year *2/ 


6/ Rapport Annuel Bio-Statistique du Service de la Sante' Publique 
1947, table 3* * 

2/ Ibid , table 4» 




- 47 - 


Table 15 

Beds in Public General and Maternity Hospitals 

(March 1951) 


Public hospital 

Total 

Public 

wards 

Private 

Semi¬ 

private 

Cap—Haitx6n 0 o©oo©ooooo©o 

265 

255 

10 


o OOOOOOO® 00© 

44 

36 

6 

2 

Gonaives. ©oco©oooo©o©oo© 

75 

72 

3 

- 

ilinche o OO <5000000000 o c o o o 

75 

72 

3 

- 

St o Max' Coooooooooo © o o o o o 

70 

66 

2 

2 

IB G^Xad^ oo ©OOOOOOOo© OOO 

Port-au-Prince 2 

40 

40 

— 

cu 

General Hospital,, 0 . 0a 

517 

488 

14 

15 

Maternity Hospitals»« 

100 

100 

- 

- 

Jacmelo ©o©oo©o©ooo©©®ooo 

100 

89 

7 

4 

Petit GOaVe • ooooooa»oeoo 

68 

66 

2 

— 

J^reime oo©©o©©o©oo©o©ooo 

85 

81 

4 

=• 

Les Gaye s©ooo©ooooo©oo©o 

137 

131 

4 

2 

Total© ooooooo«©oooo 

1,576 

1,496 

55 

25 


Sources Department of Public Health, March 9, 1951o 


o 








” 48 


Table 16 

Ratio of Beds to Population in the Departements 
and Hospital Districts 1/ 

(March 1951) 


Departement or 
hospital district 

Beds in public 
hospitals 

Persons per bed 

Departement 

XJOlfiXl© 0 0 © © oooooooooeoo 

265 

2,038 

NOX > "tllW 0 S“b oooooooooeooo 

44 

3,826 

Artibonite,. 0 0 „ 0 » .. 0 . • 

220 

2,585 

TTp<s+ p / 

• * wO 0000 OOOOO OOOOOO 

825 

1,327 

SOII'bll 0000 0000000 000 000 

222 

3,334 

AH 90000000000000 

1,576 

1,975 

Hospital district 

Cap~Haitien© ooooooeooo 

265 

2,038 

Port-de-Paix».* „ . e ,.. e 

44 

3,826 

Gonaive Soooo©o»©oooo© o 

75 

2,422 

itHT-Oha ooeooooooooooooo 

75 

1,340 

S L 0 Ma 1* 0 0 0 0 c 0 © 00000000 

70 

3,236 

Belladere ©oo©oooooo©oo 

40 

3,896 

Port-au-Prince „, 0 • 0«• „ 

617 

780 

JSr0in©X0 000 0000 000 00 000 

100 

2,464 

Petit Goave„ 0 0 * 0 „»•.• c 

68 

5,196 

OOOOOOOOoOO O OOO 

85 

2,615 

Lss Cay aSooooooooooooo 

137 

2,743 

Ail 0 ooeoooooooooo 

1,576 

1,975 


1/ General and maternity hospitals only 5 excludes beds in 
the tuberculosis sanatorium c 

2/ The public hospital in Petit Goave is here grouped in the 
Ddpartement of the West, though the Petit Goave Hospital 
District includes areas -which are in the Ddpartements of 
the West and the South. 









- 49 - 


Table 17 

Public Dispensaries in the Various Ddpartements 
and Hospital Districts 


Departement 


Dispensaries 


or 

hospital district 

“Standard“ 

“Non-Standard 11 

Ddpartement 

North.... 

9 

21 

Northwest............ .. 

- 

11 

Artibonite.. 

8 

15 

West...................... 

12 

31 

South.. 

14 

20 

All.................. 

43 r ■ 

98 

Hospital district 



Cap-Haitien............... 

9 

19 

Port-de-Paix.............. 

- 

11 


4 

7 

Hxncll0 eeoo ••0900*0090900»0 

2 

3 

St I*C 00»900009*000000e00 

2 

7 

Bellad^re................. 

3 

2 

Port-au-Prince............ 

5 

15 


1 

12 

P0tlt GOclV© oooeooeoooeeaoo 

9 

3 


3 

8 

uayes ....oo.........oo.oo. 

5 

11 


All.. 


O 0 9 0 0 oooooooooog 


43 


9S 





















- 50 - 


This appears to reflect in the main that these hospitals——especially 
the larger ones—operate at or near full capacity throughout the year 0 
For the fiscal year 1949-1950, the total nuiriber of admissions was 
28,526 (2,377 per month). 

Services rendered to in-patients in the general public hospitals 
in 1947 are summarized in table 18. In the aggregate, 30,411 cases 
received 382,874 days of in-patient care, with an average stay per case 
of 12.6 days. This average varied rather widely—from a low of 7.2 
days per case in the Port-de-Paix hospital to a high of 22.0 days per 
case in the hospital at Hinche.8/ 

The annual reports of the Department of Public Health show about 
353,000 patient-days of care in the public hospitals for 1945, and 
about 383,000 days for 1947. This reflects increases in some hospitals 
and decreases in others, the largest increases having occurred in the 
General Hospital in Port-au-Prince. 

Related to population for Haiti as a whole, these figures 
(estimated for 1950 from preliminary data) imply about 0.13 patient- 
days per person. They also indicate the variations in different 
places, with as little as 0.03 patient-days per person in the St. Marc 
hospital district as against 0.38 patient-days per person in the 
Port-au-Prince hospital district (table 19). 

The general public hospitals provided in 1947 a total of 
280,548 consultations in their dispensaries, and these were supplemented 
by 209,668 in the attached rural dispensaries (total 490,216). The 
corresponding numbers of dispensary treatments were 316,910 and 99,690, 
respectively (total 416,600).^/ 

The Department of Public Health reports that operation of all 
the general public hospitals costs 0144,371 per month ($346,500 per 
annum), equivalent to about $0.75 per patient day. 10/ This is an over¬ 
all figurej it includes the cost of the out-patient services at the 
hospitals and is therefore somewhat high if applied to in-patient 
services only. 


8/ These figures include 5,724 newborn without illness, who accounted 
for 38,737 days of hospitalization. Exclusive of the newborn, 
there were 24,687 cases, receiving 344,137 days of hospital care 
or 13.9 days per case. 

2/ Rapport Annuel Bio-Statistique du Service de la Sante' Publique* 
1947, table 11. 

10/ Exclusive of capital costs—which would not significantly affect 
this figure. 



- 51 - 


Table 18 

Services Furnished in the General Public Hospitals 

(1947) 


Public hospital 

Cases 

Patient-days 

Average 
stay (days) 

Cap-Haitien . . 

3,612 

65,500 

18.13 

Port-de-Paix.. 

613 

4,388 

7.16 

Go naive s.. 

1,345 

20,633 

15.34 

Hinche.............. 

1,120 

24,630 

21.99 

St.Marc.. 

1,662 

15,979 

9.61 

BelladSre 1 /....... . 

— 

— 

— 

Port-au-Prince 2/. .. 

15,721 

158,897 

10.10 

Jacmel* ooooeo ©<> © c o © o 

1,800 

20,541 

11.41 

Petit Goave ......... 

916 

17,572 

19.18 

J^remie. ............ 

1,993 

21,179 

10.62 

Les Cayes.. 

1,629 

33,555 

20.59 

Total.... 

30,411 

382,874 

12.58 


1/ Not in operation in 1947. 
2/ General Hospital only. 


Source: Rapport Annuel Bio-Statistique du Service de la 
Sante Publique, 1947, tables 50 and 51o 














- 52 - 


Table 19 

Days of Hospital Care per Capita 


(Public hospitals only) 


Ddpartement 

or 

hospital district 


Estimated patient- 
days per person 
(1950) 


Departement 

North 
Northwest* 
Artibonite 
West 
South 


oooooooeoo 


© o e o o 


© o © o o 


©ooooooooo 


000000900 


© © o © o © 

o r> © o © o 

© C O O 9 C 

0 0 0 0 9 0 

O O O o 0 © 


O 0 O o 

9 0 0 0 

0 9 0 0 

0 9 0 0 

0 9 9 0 


0.13 

*04 

*10 

.18 

,08 


All. 


o o co © o 


© O • O O 9 9 


0 9 0 


O O 


0.13 


-0 0 0 9 


0 9 0 0 0 


© O O © O O 


Hospital district 

Cap-Haitien,.,, 
Port-de-Paix, 
Gonaives.. 
Hinche.... 

St.Marc, 
Bellad^re, 
Port-au-Prince.. 
Jacmel, 

Petit Goave, 
Jdremie, 

Les Cayes, 


oOOeooooo 


'0 0 0 9 0 


• oooooeooe 


•9000 


OOOOOOOOO 


> O O O © o © o 


© © © © o o 

O 9 © © O 9 

0 9 0 0*0 

• 0 9 0 9 0 

• 0 0 0 9 0 

0 0 0 9 0 0 

0 0 0 9 0 0 

9 0 9 0 9 0 

0 0 0 9 0 © 

9 0 0 0 9 0 

0 9 0 0 0 0 


© o o o o e 

© o O O 9 o 

o o o o o o 

o © 9 O © 9 

0 0 0 0 9 0 

O O 9 O C O 

© O 9 © O O 

0 0 0 9 0 0 

O O O © O O 

O O 9 9 O O 

9 0 0 0 0 9 


0.13 

*04 

*13 

*23 

*03 

( 1 /) 

<>3S 

.10 

*04 

.11 

*07 


All 


O O O O 9 O 


0.13 


1/ Not available. 







- 53 - 


The Public Hospitals in Port-au-Prince 

Of the 1,576 beds in the public general and maternity hospitals 
of Haiti, 617 or 39 percent are in Port-au-Prince—in the General 
Hospital and the maternity hospital (Hopital Isaie Jeanty). 

The General Hospital 

This, much the largest and most important hospital in Haiti, is 
reported to have 517 beds (March 1951)o They are divided as follows* 

Beds 


Private rooms. 14 

Semi-private rooms. ....... 15 


Public wards................... 488 

Charges ,—For the private room beds, the charges are $3-$4 per 
day. The services of the physician are not included in the charges for 
the private beds. There is no fixed fee schedule. Payments are made 
to the hospital, and vary from $30 to $100 per case. Officers and 
employees of the Government are entitled to a 50 percent reduction in 
charges for bed and treatment. Medical and nursing attendance is free 
for occupants of the semi-private beds. For 6 private-room maternity 
beds, the hospital makes an over-all charge of $55 for the whole case 
(including food, medical and nursing attendance, etc.); for each of the 
3 semi-private maternity beds the charge is $35. The average stay is 
now reported to be 7-9 days. 

For the beds in the general public wards, the in-patients pay 
nothing. They receive food, medical and nursing care, medicines, etc. 

In some complicated cases, they may arrange from outside the hospital 
staff for specialized services not available within the staff. For the 
patients in the maternity wards, there is a charge of $1 at termination 
of the case. The average stay is 7-9 days. The administration is 
considering a policy of asking all patients in the public wards to make 
H a gift” to the hospital, at time of discharge, according to their means. 

Operating finances .—The budget allotment for the whole General 
Hospital for 1948-49 was 089,178 per month. At the end of the fiscal 
year, the Hospital returned a balance of 028,000 to the public Treasury. 
The budget for 1949-50 was 0100,948 pel* month. 034 was returned to 
the public Treasury at the end of the year, and there was a net deficit 
of about 04,000. 

Receipts from patients are used for the operation of the hospital 
and do not appear as such in the Government Budget. All patients are 
served by staff of the hospital who are paid by the Government; and the 
costs of bed, board and treatment for the private and semi-private 
patients—as well as for the public ward patients—are a charge on the 
hospital. 









- 54 - 


It is reported that physicians have proposed to the adminis¬ 
tration that they should receive 25 percent of the fees paid by the 
private and semi-private patients. 

Receipts from private and semi-private (including maternity) 
patients were 068,150 for the fiscal year 1948-49® (No data are 
available for 1949-50.) 

The total budget reported here (about 0100,000 per month) divided 
among about 15,000 patient-days per month is equivalent to 06-07 ($1.20- 
$1.40) per patient day.11/ This figure includes the cost of out-patient 
services, and is therefore somewhat too high as a cost for in-patient 
services only. 


In-patient services and occupancy rate .—In 1947, total cases 
were 15.721.12/ with little variation in admissions from month to 
month.13/ The average daily patient census for that year was 485.14/ 
Total in-patient services calculated against the reported number of 
cases, were as follows; 


1247 


Cases 

Patient 

days 

Average 
days per 
case 

TO*fccil© eeooooeoooeooeooo © lf)j721 

158,897 

10.1 

Maternity (normal).... 4,182 

27, %S 

6.6 • 

Newborn (normal)...... 3,920 

23,892 

6.1 

All other s*ooo..o.oa.o 7,619 

107,547 

14.1 


Total admissions for the period July 1949-June 1950 were somewhat 
lower—14,872. Maternity cases now number aboufc 313 per month. 

The Administrator of the Hospital reports that the occupancy 
rates have been and are approximately as follows; 

Beds in public wards..................... 100 percent 

Beds in private and semi-private rooms... 90 percent 

Qhtrpatient services .—Patients served in the out-patient clinics 
receive services (medical and surgical consultations and medicines) free 
of charges, except as noted below. The General Hospital supplies only 
basic medicines; other medicines (prescribed specialties ) have to be 
purchased privately by the patients. 

11/ Exclusive of capital costs. 

12/ Rapport Annuel . 1947, tables 50 and 51. 

13/ Ibid , table 3. 

14/ Ibid , table 4. 











- 55 - 


Out-patient services in 1947 'were as follows: 

Consultations Treatments 

Total esoaoooooocoooooooooooooe 144, 337 125, 036 

At the General Hospital...* 110,755 113,724 

Related Dispensaries,,«.*. , 33,582 11,362 

Eye a ear, nose and throat .—With the exception of indigent 
patients, those served in these clinics are required to pay $0*50 per 
consultation, and $5°00 for operations (once a week). 

X-ray, laboratory, etc Patients served in the clinics are 
required to pay for various kinds of examinations, according to a fee 
schedule. This applies to X-ray examinations, blood chemistry, urine 
analysis, etc. Fees for radiographic services range from $5 to $30. 

It is estimated by the Administrator of the Hospital that the 
out-patient services use about one-third of the medicines and other 
supplies furnished by the central pharmaceutical and other services. 

Expansion of the Hospital .—The Administrator advises that 
expansion of the Hospital could be readily achieved. For an additional 
100 beds—which could be served by the central facilities—it would 
be necessary to construct at least 3 new wards, each containing 30-35 
beds. Such an addition of 100 beds would require additional personnel 
as follows: 


Per ward Total 


Physicians, 

Nurses,• 

Attendants, 
Administrative persons 


1 © 90C000 Oi>0 O O 


oooooooooooooo 


► o © o e gooooooo 


eoooooooO 

ooooooeo© 

0 0 0 6* ©O®0 

® OOOOOOOO 


2 

6 

3 


6 

18 

9 

2 


New hospital construction ,—The General Hospital in Port-au- 
Prince is long past its useful life. It is inadequate for good hospital 
care—such as is feasible in Port-au-Prince ; and its equipment is 
pathetically deficient. 


The Government is giving careful consideration to the construction 
of a new general hospital, and to the reconstruction of part of the 
present hospital to serve as an adjunct. This is part of a larger 
program which is also concerned with new and equally badly needed 
facilities for the medical (etc,) schools, the nursing school, a nurses* 
residence, etc. A survey has been made by a consultant from the PASB 
(WHO) and preparations are being made for architects* designs. At this 
time (March 1951), it appears that if the construction program is 
initiated promptly, the new hospital and related facilities could be 
ready for use about July 1, 1953 or soon thereafter. 









- 56 - 


The, Maternity Hogjaitel 

The Hospital Isaie Jeanty is a 100-bed maternity hospital 
opened in 1948. Twenty beds are reserved for cases with complications 
of pregnancy, Of the remaining 80 beds, 5 are reserved for infected 
eases and for emergencies. The hospital is served by a staff of 5-7 
physicians, 8 trained (obstetrical) nurses and 6-7 midwires. Its 
occupancy varies from 75 to 100 percent, with an average patient stay 
of 8-9 days. 

Admission and service is substantially free; the hospital admits 
all cases that apply. The patient is charged only $10,00 ($2,00) for 
the entire case. The public Budget provides the cost of bed, board, 
medical and other attendance and medicines. The income from patients 
pays the cost of special medicines. 

During the fiscal year October 1949-September 1950, there were 
about 3,000 deliveries (minimum 221 in February 1950; maximum 297 in 
July 1950), There are about 250 per month now (March 1951), 

The total budget for board, etc,, is $3,802 per month, (In 
addition to the patients, 26 other persons are fed at the expense of 
the hospital,) Average cost of board (126 persons) is $1,00 per day. 
Medicines and related supplies cost $54,000 a year, equal to $18,00 
(43o60) per delivery. Together, board and medicines, etc,, cost 
$L00,Q00 for the year. This is equivalent to about $4 ($0.80) per 
patient day and about $33 ($6,60) per delivery. Salaries (physicians, 
nurses, midwives, and other personnel) cost about $30,000 per year 
(about $10 per case and about $1.20 per patient-day). Thus, the total 
cost per patient-day is probably about $2, including bed, board, 
medicines, and medical and nursing attendance but not including 
capital costs. 

Infant deaths in the year 1949-50 were 132 (minimum 5 in 
November 1949; maximum 17 in January 1950). There were 5 maternal 
deaths during the year. 

The hospital can be readily expanded—by adding wings or building 
units to provide wards of 30, 50 or 100 beds, and to provide seiKl-private 
wards or rooms, and by adding delivery rooms, etc. 




- 57 - 


Other Professional Personnel 

Dentists 

It is reported that Haiti had (mid-1950) a total of 74 licensed 
dentists, one per 42,000 persons in the total population* Of these, 

66 were in private practice and 8 were employed by the Department of 
Public Healtho The total number is equivalent to one dentist per 
42,000 persons* Their geographical distribution is shown in table 20* 

0f the total of 66 dentists in private practice, 44 (two-thirds) 
were located in Port-au-Prince* The 8 dentists employed by the 
Government were distributed among 7 cities in 4 d^partements (Appendix 
table 13 )* It is reported that the number has increased somewhat 
(March 1951)o 

Pharmacists 

It is reported that, in mid-1950, Haiti had 83 registered 
pharmacists* Their geographical distribution is shown in Appendix 
table 14, and may be summarized as follows— 


Departement 

Number 

Persons per 
pharmacist 

North 000090099 90090 

6 

90,033 

Northwest o©©oooooo© 

2 

84,173 

Artibonite * * *«* * * *» 

8 

71,083 

We St © © 0009000090000 

54 

20,269 

So uth o ooooooo© ooooo 

n 


Total© o o o e o o O 

83 

37,494 


It is reported that altogether there are 375 pharmacies and 
125 persons serving as pharmacists* 

Nurses* Midwives* Aides, etc* 15/ 

It is reported by the Department of Public Health that there 
are 218 nurses in Haiti, as followss 


15/ For public health nurses and aides employed by the Department of 
Preventive Medicine, see Appendix table 15 ; for nurses employed 
in the Department of Public Health (Division of Preventive 
Medicine)—in the headquarters offices, health centers, etc*, see 
Appendix table 16; for nurses 9 salaries by type of employment 
(hospitals, clinics, etc*), see table 23* 












- 58 - 


Table 20 

Geographical Distribution of Dentists 


Departement 
or 

hospital district 


Persons 

per 

Number dentist 


Ddpartement 

North 0000090 . OOOO0OO.*««OOQOO b 

Northwe St ooo.ooooooooooo.oooo 3 

Artlbonite o.ooeoooooocooooooo 7 

e St e00900000*4000oefi9t0*40oe b-9 

SOUthoooooooo.«oooo»oo*.ooooo 0 


All 


ooe«oo«oeooooe 


o o o o o 


74 


>00 0 0 0 0 0 


Hospital district 

Cap-Haitien„.. 
Port-de-Paix.. 
Gonaives 
Hinche 
St.Marc 
Bellad&re 
Port-au-Prince 
Jacmel 
Petit Goave 


o o 

o « 

o o 


O 0 o • o • © 

O © O O O O 0 

9 9 O O O • O 


o © O O 

0 9 0 0 

0 9 0 0 


’0 0 9 0 0 0 


ooooocoooeoee 


’ O O O 9 9 0 


o o 

o o 


9 0 9 

COO 


0009 ooooooeoeo 


Jerernie 


Les Cayes 
All 


900000900 


0000900000900 


ooooooooooo 


9 0 0 0 

9 0 0 0 

0 0 9 0 

0 0 9 0 

o o o o 

9 0 0 0 

O O O o 


0 9 0 0 

o o o © 

0 0 9 0 
9 9 9 0 
9 0 0 0 

9 9 0 0 

9 0 0 0 


OOOOOOOOOOOOOOOO'OOOOO 


6 

3 

3 

2 

2 

46 

3 
1 

4 
4 

74 


90,033 

56,115 

81,238 

22,337 

82,241 

42,054 


90,033 
56,115 
60,543 
50,251 
113,266 

10,458 

82,135 

353,325 

55,565 

93,937 

42,054 








- 59 - 


In the Department of Public Health.,..... 207 
In private clinicso oo.oooo©oooo©o« 0 . 00 . 0 . 10 

In an industrial clinic..©....... 0 •.....» 1 

Their average salary is given as $50 per month. 

There are 35 “auxiliaries" (aides) in the public hospitals, 
employed at salaries of $ 20-$50 per month; also 52 "panseurs" 
(dressers) and 83 “sisters . 11 

There are 47 mid-wives in Haiti. 

Special Facilities in Industry 

Only the following industrial establishments are reported to 
have clinics ( 1-4 beds each), served by a physician and nurses: 





Personnel 

Establishment 

Beds 

Disp. 

MD 

Total 

Plantation Dauphin ....... 0 

12 

2 

3 

7 

Haitian Agr. Corp. . •..... 



1 

2 

Shada (St. Marc).......... 



1 

2 

Shada (Foret des Pins).... 



1 

2 

Hfii SCO 0 00000 000000 0 0 e 0 0 e 0 00 

2 


2 

4 

Standard Fruit ...o........ 

—— 

— 


_£ 

T 0 "t? al OOOOOOOOOOOOOOO 

14 

2 

9 

19 


Public Health Personnel 


Reports from the Department of Public Health show total 
personnel of 206 for the Division of Preventive Medicine, and 125 for 
the Division of Sanitary Engineering. In the former, there were— 


Phy SIClan Soooooo.ooooo.ooooooooo.eo.oo 4^ 
Dentists .qo.oo.ooooqoooooooooooo.o»»oo 8 

Pharmacists. 0000000000000 . 0000000.0000 1 
Public health nurses and aides ... 0 •.. 0 101 
Laboratory techniciansoeoeoooooo..oooo 12 
Other personnelo 00000000000 .ooooooooo. 


Totalo 


ooooooooo© 


o a 


0 0 0 9 


00090900900 


206 


Their geographical distribution by hospital districts is shown 
in Appendix table 15. The 119 persons connected with the headquarters 
offices and the health centers in Port-au-Prince are shown in Appendix 
table I 60 








- 60 - 


There is no school for the training of public health personnel 
in Haiti. Special training in public health for physicians, nurses, 
sanitary engineers, etc. is obtained in other countries. 

It is estimated by the Department of Public Health that not 
more than one-sixth of the population (about 500,000 persons) benefit 
from present public health services. 

Salaries in the Department of Public Health 

Large proportions of all medical and related personnel are 
employed on a part-time or full-time salary basis in the Department 
of Public Health. It is therefore of considerable interest to note 
the amounts paid. Tabulations were prepared from the Budget for 1950* 
51. The results are shown in tables 21 (physicians), 22 (dentists), 
and 23 (nurses). The data may be summarized, in terms of averages, 
as follows: 


Average annual salaries, 
Department of Public Health 
1950-51 


Physicians 
Dentists.. 
Nurses.... 


eoooe ooooc©*©oo ooco©o»o © o © © © e © © o 


$1,567 

1,126 

630 


Account should be taken of the fact that for the physicians and 
dentists who engage in clinical work these are only part-time salaries 
(5 hours per day), supplemented by private service for fee outside their 
regular hours of employment. Also, that the salaries of nurses are 
reported to be grossly insufficient to sustain adequate recruitment, 
maintenance or expansion of personnel. 





- 61 


Table 21 

Salaries of Physicians 
(Department of Public Health) 


Type of 
employment 

Average 

annual 

salary 


Number -with specified annual 

salaries 

Total 

number 

$2,400 

to 

3,000 

$1,800 

to 

2,280 

$1,260 

to 

1,680 

$1,200 

$720 1/ 

All types.. 

$1,567 

148 

6 

46 

37 

52 

7 

Administration 
(Departmental).• 

2,018 

4 

2 

— 

1 

1 

- 

Sanitation, health, 
education, etc.* 

1,698 

5 

— 

2 

3 

- 

- 

Faculty of 
medicine. 

1,650 

27 

2 

8 

9 

8 

- 

Consultant 
services........ 

1,514 

15 

— 

4 

5 

6 

- 

HOSpitalSoo«eo««e 

1,533 

81 

2 

28 

14 

30 

7 

Clinics, dis¬ 
pensaries and 
health centers.. 

1,494 

16 

— 

4 

5 

7 

— 


1 / Internes and residents,, 


Based on tabulations from the Budget for 1950-51• 











- 62 - 


Table 22 

Salaries of Dentists 
(Department of Public Health) 


Number with specified 
annual salaries 


Type of 
employment 

Average 

annual 

salary 

Total 

number 

$2,160 

$1,620 

to 

1,680 

$1,200 

$840 

to 

980 

$720 

All types............. 

$1,126 

30 

1 

6 

6 

12 

5 

Faculty of dentistry.. 

1,323 

18 

1 

6 

6 

5 

- 

Ho S O © O © ••0000009 

7 BO 

6 

- 

— 

- 

2 

4 

Clinics, dispensaries 
and health centers... 

878 

6 




5 

1 


Based on tabulations from the Budget for 1950-51. 








- 63 - 


Table 23 

Salaries of Nurses 
(Department of Public Health) 


Type of employment 

Average 

annual 

salary 

Total 

number 


Number -with specified 
annual salaries 

$840 

$780 

$720 

$660 

$600 

All types.. 

$630 

205 

1 

2 

18 

57 

127 

Faculty of nursing, etc.... 

645 

4 

— 

— 

•— 

3 

1 

Hospitals.. 

630 

160 

— 

2 

14 

45 

99 

Clinics, dispensaries and 
health centers...... 

628 

34 

— 

— 

4 

8 

22 

Visiting nursing... 

643 

7 

1 

— 

— 

1 

5 


Based on tabulations from the Budget for 1950-51. 











- 64 - 

CHAPTER V 


Sickness and Maternity Insurance 


Review of the proposed system of sickness and maternity insurance 
is limited by the data that are available. This applies especially to 
quantitative inspection of coverage, costs and contribution rates. The 
analysis presented in this chapter therefore follows an unconventional 
procedure. It proceeds by considering application of insurance speci¬ 
fications first to limited coverage in the Port-au-Prince area, second 
to broader coverage in this area, and finally to all employed persons 
throughout Haiti. 


Limited Coverage in Port-au-Prince 


Limited coverage in Port-au-Prince and its environs is assumed 
to include regular and substantially full-time enployees in both private 
and public establishments. Private employment is considered to include 
commerce and industry; but at this point it does not include either 
domestic employees in private homes or the seasonal employees in the 
agricultural and related establishments with headquarters in Port-au- 
Prince or in nearby places. 


Coverage 


The 1949 census of Port-au-Prince suggests that such a coverage 
might extend to approximately the followings 


Private employers ...... 

Private establishments .................. 

And it might cover the following persons: 

Private employees ....................... 

Public enployees ......o................. 

Total enployees oo.oocooo..o...o.... 


1,800 

1 / 

1,000 

y 

10,000 

3 / 

6,000 

4 / 

16,000 


1/ Based on the census of Port-au-Prince, 1949. 

2 j Approximately twice the number covered by the Bureau of Labor survey 
of April 1950. (See Chapter III) The number of establishments 
(1,000) is less than the number of employers (1,800) because many 
enployers do not operate from fixed establishments. 

2/ Approximately four times the number covered by the Bureau of Labor 
survey, and based on the census of 1949. 

V Based on the census of 1949, The third survey of public enployment 
suggests that this number may be too high for Port-au-Prince except 
when the number of Government enployees engaged in construction. 
/ e £nn rs other public works is large. The excess over 3,500 or 
4,000 may be subject to considerable fluctuation within a year or 
from year to year. Continued general increase in the Government 
budget and employment operates to justify the figure used in this 
analysis. 













- 65 - 


Of these employees* about 15*000 would probably have a sufficient amount 
and continuity of covered employment in the course of a year to qualify 
for insurance benefits,, This number would be further reduced if the 
insurance coverage excluded employees with earnings in excess of some 
specified maximum; but such an income exclusion is tentatively ignored,, 

There are no adequate data for a reliable estimate of dependents* 
The available information (see chapter III) suggests that these would 
be* on the average* between 1 and 2 qualified and eligible dependents 
per insured employee c j>/ Thus* the total estimates for the limited 
coverage are: 

Insured (qualified) enployees •••••..,. 15*000 

Insured dependents ...... 0 .. * * *. *. *«* * * 15*000-30*000 

Total eligibles * * * * * *. * * * *.. * * * * * 30*000-45,000 

Contribution Income 

The basic data on earnings used in this analysis are those 
■which can be derived from the surveys of private and public employment 
conducted by the Bureau of Labor for the purposes of this study (see 
chapter III)* They are summarized in table 24 and in Appendix tables 
17, 18 and 19* 

This first financial analysis uses not the insurance specifica¬ 
tions contained in the law of October 1949* but those in the current 
draft of a revised law* It assumes compulsory coverage of enployees 
with earnings up to $500 per month* but with the contribution rates 
applicable only to earnings up to $300 per month* This is an inter¬ 
mediate type of specification betweeng 

(a) The specification in the laws compulsory coverage 
of only those with earnings up to $300 per month* 
and this amount subject to contributions; and 

(b) A broader specifications compulsory coverage of 
all enployees (regardless of earnings)* with up to 
$500 per month subject to contributions* 

The earnings data used here are in tne form of annual earnings. 
They were derived by multiplying average monthly earnings by 12* 
inplying that these are the earnings of persons who have year-round 
employment. 


j J Fragmentary data suggest that qualified dependents may be nearer 1 
than 2 per insured eirployee* but the range used here seems to be 
necessary until more reliable information is available* 





- 66 - 


From the survey data it is calculated that the following average 
annual earnings would be subject to the insurance contribution rates 6/ 
for sickness and maternity insurance coverage in and near Port-au-Prince: 

V 

• Per employee 

Private employees $ 360 a year 

Public employees 526 11 H 

All employees 2/ 413 " M 

The total annual earnings subject to insurance contribution are 
therefore estimated as $6,610,000; and each 1 percent of contribution 
for sickness and maternity insurance equals $66,100* or $4.13 per 
covered employee and $4441 per insured employee. Contributions at the 
rate of 8 percent (employers and employees combined), as specified in 
the law, would yield about $33o04 per covered employee and $35.28 per 
employee eligible for insurance benefits. (All of these figures will 
be changed if the specifications for ©overage are amended.) 

Cost of the Cash Benefits 

Wage-loss benefits .—The Social Insurance Law of October 1949 
specifies benefits payable from the 5th day of incapacity, without 
limit on duration. The benefit rate is 50 percent of basic wage, plus 
10 percent for each dependent up to a maximum of 70 percent. The 
revised draft bill proposes a longer waiting period, a limit on the 
duration of benefit, and a uniform rate of benefit regardless of 
whether or not the incapacitated employee has dependents. 

For the purposes of this analysis, the very liberal (and 
potentially much more expensive) benefits in the law have been discarded 
in favor of the more conservative benefits in the revised draft bill. 

The main specifications used here are as follows: 

Benefit rate 6? percent of basic wage 8/ 

Waiting period 7 days 2/ 

Maximum duration 26 weeks 

6/ Compulsory coverage of those with earnings up to $500 per month, and 
contributions on earnings up to $300 per month. With respect to 
public employees, the earnings were derived from the first two 
surveys$ the results of the third survey were not available in time 
for use in this connection. Use of the data from the third survey 
would have increased the average for public employees in Port-au- 
Prince from $526 to $544 a year. 

7/ Combined in the same proportions as in the estimated coverage (ID and 
6, respectively). 

8/ May be reduced, under regulations, by one-half during hospitalization 
of insured employees who have no dependents. 

2/ No waiting period for an incapacity beginning within 60 days after a 
previous incapacity. 







- 67 - 


Table 24 

Average Annual Earnings According to Earnings Limit* 

Public and Private Employees 

/ ■ 


Annual earnings ($) 
per annum 



Employees and earnings 

Port-au- 
Prince 1/ 

Haiti 2/ 

1. 

• * _ * 

-A.jL._L 0 lTLjL) 1' O r ^V* 00Sooooo 0 0 0 0 0 0 000 090 e 0000 0000 0 00 c 

la 0 Excluding earnings in excess 

584 

478 


O i ^ 5 00 / ISO 0 OOOOO 00.00 0 0000 000 000 9 000 

lbo Excluding eamin'gs in excess 

528 

439 


oi 0300/mO 0 ©00000090© OO 0000900000 00 

446 

387 

2 e 

Employees earning not more than $500/mo o 00 

2a 0 Excluding earnings in excess 

438 

375 


Oi 0300/mO © oeoooo 00 000000000 oooeooe 

413 

363 

3. 

Employees earning $301-$500/mo 0 «, 0 . „ c «,»» e « e 

934 

925 

4o 

Employees earriing not more than $300/mo 6 <><, 

373 

327 

5* 

Employees earning $110-0150/mo a „ Q 0 • 0 <> » • . • e 

280 2/ 

301 ii 

6 * 

Employees earning less than $110/mo e et ,o 000 

228 y 

2241 / 

7. 

Snployees earning $501/mo. and more, <> 0 «» . 0 0 

1,776 V 

1,892 4/ 


l/ Earnings of public and private employees combined by weighting 6 and 
10, respectively—the proportions expected fo’r limited coverage in the 
Port-au-Prince area, 

2/ Earnings of public and private employees combined by weighting 10 
and 90 percent, respectively 0 

2/ With respect to public employees, based on the first survey c 
4/ Assumes average of $600 per month for public employees. 








- 68 - 


The special surveys show the following amounts of sickness 
absenteeism per employee in the course of a years 

Public employees 2,1 workdays 

Private employees 10/ 2,5-3.2 H 

These figures cover all durations of incapacity and all cases, 
whether work-connected or not. Exclusion of the cases lasting less 
than 8 days (i,e., cases with durations that are tfaolly within the 
waiting period) eliminates about 50 percent of the cases and about 
11 percent of the days of incapacity. In morbidity statistics for the 
U.S.A. and other countries, the cases lasting less than 8 days usually 
are 65-85 percent of all cases and account for 25-45 percent of the 
days of incapacity. The survey findings (2-3+ days of incapacity per 
employee) are surprisingly low by comparison with 5-15 days per 
employee in other countries. The small proportion of short-term 
cases and days of incapacity suggests that the surveyed employees did 
not abstain from work in many of the short-term illnesses that usually 
cause absenteeism, or that the surveys failed to obtain reports on 
many such cases, or both. To the extent that the survey figures are 
low because of cases and days that last or-—if the employee had stayed 
away from work—that would last less than 8 days, there is no error in 
using them for the estimate of wage-loss benefits with respect to 
cases lasting 8 days and longer. 

Exclusion of the days of incapacity beyond the 27th week (1 week 
of waiting period plus the maximum of 26 weeks of benefit) eliminates 
an indeterminate or negligible percentage of the total reported amount 
of incapacity. 

It is assumed here that the survey findings underestimate the 
amount of incapacity that would be compensable when insurance benefits 
are available. This is the necessary conservative assumption for the 
balance sheet in advance of actual insurance experience. 

In light of experience in other countries, it might be assumed 
here that there could be 5—7 compensable days per insured employee. 

At the benefit rate of 67 percent, these assumed rates of incapacity 
would lead to the following costs: 


Percent of covered earnings 
Assuming 300 workdays per year 1,1-1,6 

" 275 " " " 1,2-1.7 

A cost of 1,0 percent of covered earnings would be equivalent to 
4-1-4.5 compensable days of incapacity a year per insured employee. 


10/ Port-au-Prince. 








- 69 - 


It is said that the intense competition to obtain and to hold a 
job in Haiti may account for the low rates of recorded or reported 
sickness absenteeism, especially for the low rate of minor and short¬ 
term illness; and that this condition would largely persist even after 
sickness benefits become available through insurance 0 If this is 
correct, an annual expectancy rate of 3 or 4 compensable days of 
incapacity per insured worker may be sufficient and the cost would be 
about 0,7-1,0 percent of covered earnings? 

Intermediate figures may be used for this financial analysis, 
Cash wage-loss benefit may be expected to cost 1,0-1,25 percent of 
covered earnings. Actual experience may be lower or higher; btit these 
figures are probably reasonable for advance budget purposes,11/ 

Maternity benefits ,—The insurance law specifies the same 
benefits for maternity cases among insured persons as for incapacity. 
Instead, the following specifications are used here? 

Benefit rate 67 percent of basic wage 

Maximum duration 42 days 12/ 

No data are available on the maternity or pregnancy rates among 
gainfully employed women in Haiti who would be insured employees. For 
this analysis, alternative annual rates of 25 , 50, and 100 compensable 
cases per 1,000 insured female workers are assumed. This provides a 
range of from 2\ to 10 times the rates actually observed in other 
countries with insurance providing maternity benefits. 

From the special surveys summarized in chapter III, females are 
estimated to constitute 16 percent of the public and 40 percent of the 
private (insured) employees. Benefit duration per conpensable case is 
assumed to be 28 conpensable days on the average, out of a possible 
maximum of 42 days, Mth these assunptions, the cost of these benefits 
would be 0,05-0,2 percent, or 0,06-0,22 percent, of covered earnings 
according as the average work-year is assumed to have 300 or 275 work¬ 
days, respectively. 


ll/Note that no deduction or allowance has been made for so much of 
the incapacity as is work-connected and chargeable to the separate 
cost of workmen 1 s compensation, 

12/Twenty-one days before and 21 days after delivery. 


\ 







- 70 - 


Death benefits ,,—The insurance law and the revised draft bill 
specify a benefit amount equal to 3 months* basic wages© 12 / 

In the absence of applicable data, it is assumed here that Haiti 
has a general death rate of about 20 per 1,000 persons, and that the 
annual death rate among the insured persons might be about one-half of 
that general rate—about 10 per 1,000« At this rate, annual benefit 
payments in death cases would equal 30 months* of average (basic) wage 
per 1,000 insured persons, or approximately $1 in benefit per $400 of 
insurance-covered earnings© Thus, this benefit would cost about 0©25 
percent of insurance-covered earnings© 

All cash benefits ©—The costs of the three cash benefits may be 
summarized as followss 


Cash benefit 


Annual cost in 


% of covered 
earnings 


per insured 


Hfege loss 
Maternity 
Death 


lo0»l 0 25 $4o22=45o28 
0 © 05 - 0 o 22 0o21=0©93 
0©25=0o25 I 0 O 6 -I 0 O 6 


Total 1©30=1©72 $5«37-7olO 


Note o—The costs shown here have been calculated by reference 
to the average annual earnings given earlier in this chapter© To the 
extent that those earnings correctly reflect weekly or monthly earnings 
(or "basic wage 11 used for determining benefit rate;, they are a correct 
base for the calculation of cost in per insured 11 , even though 
employment is interrupted during the course of the year© This results 
because the eligibility conditions provide for maintenance of insured 
status despite approximately half-time lack of insured employment© 

However, cost in xx % of cohered earnings’* is under-estimated to the 
extent that the assumed average annual (covered) earnings over-estimate 
the amount of earnings that would be subject to insurance contributions 
in the course of a year© Later, when considering the contribution rate 
needed to finance the system, allowance will be made for this possibility© 


13/ The social insurance law provides (art© 59) that this benefit would 
be payable to dependents, but only if the decedent had been regis¬ 
tered under the insurance system for at least a year and had paid 
contributions for at least 240 days© The revised draft law pro¬ 
vides more or less similarly, but also provides for payment of the 
benefit in the absence of qualified dependents, in this case the 
money going to those who had been responsible for meeting the 
expenses of the decedent*s last illness and of the funeral expenses 
(up to the amount of such expenses)© These specifications are 
ignored here; the full amount of death benefit is assumed payable 
in all death cases© 











- 71 - 


of the Medical Benefits 

It is almost gratuitous to repeat that there is no adequate 
basis for making a precise or altogether reliable estimate of costs 
for the medical benefits* The best that can be done is to draw upon 
such information and data as are available and to approxinate the 
probable cost e Conservatism must be emphasized; and, in this 
connection, conservatism means a relatively high cost estimate,, 

For limited coverage in and near Port-au-Prince medical-benefit 
costs per capita can be much higher than elsewhere in Haiti, because 
the resources for furnishing services are very much larger in the 
capital area than in other parts of the country and because medical 
costs may be higher per unit of service* 

Both earnings levels (and, hence, contribution income) and 
medical costs are primarily as of 1949-50„ Income and outgo data 
are therefore on the same wage and price level* Both may need 
adjustment—upward or downward—for another time period and for 
another wage or price level* But as long as wages and prices stay 
in the same relation to each other as in 1949-50, costs estimated 
here in terms of percent of earnings will still be applicable* 

Both the Social Insurance Law of October 1949 and the 
revised draft bill provide an arbitrary time limit on medical benefits: 
from the beginning of sickness for a maximum duration of 2? weeks in 
the case of employees, and for a maximum of 13 weeks in the case of 
dependents, with the proviso that these limits may be extended to 1 
year in special cases (e*g*, prolonged convalescence)* For the 
purposes of this financial analysis, medical benefits are assumed to 
be available as needed, without arbitrary time limitj and no financial 
offset has been taken by reason of the time limit in the law and in 
the revised bill* 

Hospital care *—It is estimated from the available data (see 
chapter IV) that the public hospitals presently furnish annually about 
0*65 days of general and maternity hospital care per person in the 
population they serve in. and near .Port-au-Prince* This estimate is 
probably slightly high; but it j^s nevertheless used because the excess 
offsets the small amount of beS care which is furnished by private 
hospitals and clinics in the area but which is not included in the 
f igure * 


How much hospital care should be expected under the prop r pSeci 
insurance arrangement? The estimate must have due regard for all the 
information available as to need for more hospital care* And it must 
take account of the outlook for effective demand and for enlarged and 
inproved facilities for care* With these factors in mind, it is 





- 72 - 


estimated that the insurance system should be prepared to assure the 
availability of, and to pay for, hospital care benefit amounting 
annually to about 1 day of in-patient care per eligible.insured 
person* w 

An in-patient day of hospital care in Port-au-Prince (general 
and maternity) now costs about $ 1*25 or possibly less (including bed, 
board, medical and other attendance, medicines, maintenance of plant 
and equipment, etc*, but exclusive of capital construction cost)* The 
service is badly inadequate* The insurance system should expect to 
furnish much-improved care* Even if insurance benefits become avail¬ 
able in the very near future, improvements should have been made by 
that time so that the cost of an in-patient day for insured persons is 
properly about $2* Improvement to a satisfactory level, which should 
be achieved by all practical means as soon as possible thereafter, 
should mean a patient-day cost of $2*50-$2*75 when new facilities, 
more adequate staffing and service can be available to the insured*15/ 

The generosity of these dollar amounts may be illustrated by 
the following calculations* It is authoritatively estimated that a 
ward of 33 beds requires for adequate service 2 physicians (part-time), 

6 nurses, 3 attendants and 2/3 of a full-time administrative person 
(see page 55)* (This is about twice the staff now actually used,) 

Using $3,000 a year per full-time physician, $960 per nurse, $500 per 
attendant and $1,200 per administrative officer, total staff for a 
33~bed ward would cost $11,060 a year* This is the staff cost for 
about 11,000 patient-days of care. At the hospitalization rate of 
1 patient-day per insured person, the staff cost equals almost exactly 
$1 .per patient-day and per insured person* A total cost of $2-$2*75 
per patient-day still leaves $1-$1*75 per patient-day for non-staff 
costs (food, laundry, equipment, medicines, operating‘room staff, etc*) 
for in-patient care* These are ample for hospital care in Port-au-Prince ; 
and they may be augmented if the staff costs are less than the amounts 
assumed above* 

Thus, the annual cost per insured person for hospital benefit 
is placed at' $2 as a minimum and $2 0 75 as a maximum for the near—time 
future* No assumption is intended here, by the illustration used 
concerning staff costs, as to the extent to which the in-patient 
hospital care is furnished in wards or in semi-private rooms* 


14/ The revised draft bill provides a limit of 30 days* on a case of 
hospitalization^ subject to extension in special cases when funds 
and facilities will permit* 

l^/ The maximum figure is sufficient to include a pro rata share for 
amortization of the capital cost of constructing the in-patient 
facilities if the capital is derived on an interest-free loan 
basis and has to be repaid* 






- 73 - 


Clinic and home care P —Available information indicates’that the 
amount of care from physicians for ambulatory patients and for home 
care of bed patients is relatively small in Port-au-Prince* The data 
at hand, especially for clinic care, suggest it does not amount to 
$0*50 per capita per annum,, 

The insurance budget should provide adequately for clinic 
and other services for ambulatory patients and for home care—with 
due regard for the availability of physicians and the probable effective 
demand to be expected -when the service is available as an insurance 
benefito It should also provide for laboratory. X-ray and related 
services to be furnished to the ambulatory sick and to the non-ambula¬ 
tory patients served in their homes„ To these ends, it is assumed 
that the expected heeds for 15,000 insured persons can be met by budget 
allowances totalling $2 per insured employee, as follows? 


•» 

Total 

Per capita 

For payments to physicians 

$18,000 

$1*20 

For their assistants, 
supplies, etco 

4,500 

0*30 

Sub-total 

$22,500 

11.50 

For laboratory and related 
services 

$7,500 

$0.50 

Total 

$30,000 

$2*00 


The average salary of physicians employed by the Department of 
Public Health in hospitals and clinics (for the period 1949-50) was 
about $1,500 per year for part-time service i 5 hours a day, somewhat 
more than half-time) e It was about $1,700 per year, when calculated 
exclusive of the interns and residents,, -These were net incomes„ It 
,is therefore assumed that, at 1949-50 price and income levels, an 
adequate allowance for the insurance services is an average of about 
$3,000 a year per physician (net income)„16/ At this rate, the budget 
amount ($18,000) would allow for 6 full-time physicians (or an 
equivalent larger number part-time) to serve 15,000 insured employees, 

.or 1 full-time physician per 2,500 0 Thi^ is additional to the physicians 1 
services already provided in the hospital-care allowance for the care of 

in-patients, 17/ "and which amounts to about 1/4*of a physician*s full-time 


16/ It should be noted that this is an average per full-time physician e 
It would permit paying lower salaries to junior staff members, and 
considerably more than the average to senior members,, 

17/ It is also exclusive of provisions for the care of work-connected 
cases* • 



























74 - 


per 2*500 insured persons* (The two services combined allow for 1 
physician full-time per 2*000 insured persons*) The services of the 
clinic physicians would be- supported by a budget allowance of $0,30 
per capita for supplies* etc OJ) ' and of $0*50 per capita for laboratory* 

X«^ray and related services* 

. • f : . 

The figures used here are intended to be illustrative for an 
insurance coverage restricted to the employed’ persons.. If the cover¬ 
age extended to their dependents as well (a total of 30*000-45*000 
eligible for benefits)* the same per^-capita allowance would provide a 
total of $60*000-490*000 a year-for clinic and home care* These sums 
would’support.12^18 physicians (full-time), and would provide for 
their supplies and for the laboratory* X-ray and related supporting 
services* : *• 

* Dentistry o—Available data suggest that the insurance budget 
should .expect, to.pay for the services of dentists-at a rate which is 
about two^thirds the rate applicable to physicians (an average -net 
income of $2*000 a year per full-time dentist)* Having regard for the 
very limited, supply of qualified dentists, and the low level of 
effective public demand for dental care, it is assumed here that it 
is sufficient to allow for one-third as many dentists as physicians. 

This calls for a budget of about $0*27 per capita for dentists* With 
an additional equal amount for supplies and supporting services, the 
total is about $0*55 per eapitafor this benefit service* This would 
provide about $8*250 a year for a coverage of 15*000 eligibles (about 
2 full-time dentists* plus supplies and supporting services)j and it 
would provide $16*500=424*750 (about 4~6 dentists, plus supplies and 
supporting services) for 30,000-45^000 eligible employees and dependents. 

Nursing and nur sing-aid .— In addition to services of these kinds 
already provided in previous items bf hospital and .medical benefit, 
available information suggests an additional allowance of about $0*20 
per capita* This would provide $3,000 for 15,000 eligibles (and $6,000- 
$9,000 for the larger coverage of employees and dependents) for supple¬ 
mentary nursing and-nursing-aid—especially for home nursing on a 
‘‘visiting*’ or ’’hourly” basis* • • 

Medicines and appliances **—It is well known when budgeting 
for insurance services that drugs^’ medicines, home'remedies, eyeglasses 
and other appliances, etc** can consume as much money as the insurance 
fund will supply* Most of such expenditure, especially for medicines* 
has little real value and contributes substantially little or nothing 
toward the prevention of disease,^.the shortening of illness or 
incapacity* or the acceleration or assurance of recovery* • • 

# * •* 

- * Even if insurance benefit is restricted to medicines and 
appliances prescribed by the physician or dentist, expenditures for 
this benefit tend to be grossly excessive—particularly when the 







- 75 - 


services of physicians,'-'dentists* -nurses, laboratory, technicians, etc., 
are readily available to the insured person. But since the patient’s 
expectancy and demand'for medicine is.persistent, a generous but still 
limited provision is made—^0.50-$l o 0Q per capita per annum, with the 
hope that firm administrative practice mil hold the expenditure to 
the lesser'figure-^hich is included in the-budget here. * This is-an 
allowance for prescribed -medicines, home remedies 'and appliances in 
addition to the amounts of raonejf already included for such commodities 
in the budget allowances for hospital care, other physician services, 
dentistry, etc. • 1 • 

. i ' *. 

• % 

Preventive 'services .—It is of the utmost importance, in the 
interest of both the effectiveness of the'program and efficiency in 
the use of the insurance funds, that the insurance system should do 
whatever it can to prevent illness and incapacity. Personal preventive 
services and education, general-health educational activites, and 
special preventive * health programs which‘are especially‘useful to the 
insured population should be supported, aided or performed through 
insurance funds. Care should be taken, however, that these preventive 
services do not supplant or duplicate activities of the Department of 
Public Health or of other public or private agencies that are.prepared 
and equipped to furnish such services. For'these'purposes-, an allowance 
is made in the budget' approximately equal to 5 percent of other benefit 
costs—$0.25-$0«35 per capita. This is intended to be only a minimum, 
to be increased as rapidly as funds and personnel permit, so that the 
maximum is done to prevent sickness and incapacity. 

Contingent fund .—Finally, an amount equal to about 5 percent 
of benefit costs is added to provide for a contingency fund-—to meet 
costs not otherwise budgeted and to cover marginal costs which exceed 
itemized allotments. - * 

All medical benefits.—The several medical-benefit estimates 


may be summarized as 

follows* 

'Annual cost 

($ per insured) 

Perbent 

of‘total 

Medical benefit 

Minimum or 
early year 

Maximum or 
later year 

Minimum or 
early year 

Maximum or 
later year 

Hospital care 

$2.00 

$2.75 

. 34.8 

41.0 

Clinic and home care 

.. . 2.00 

2.00 

34.8 

• 29.9 

Physicians (clinic. 


. . 

. 

26.1 

• 

office, home) 

1*50 

,1.50 • 

22.4 

* Laboratory, X-ray,etc. 

0.50 

0.50 ' 

8.7 

7.*5 

Dentistry 

0.55 

0.55 

9o5 

8.2 

Home nursing 

0.20 

0.20 

3.6 

3.0 

Medicines and appliances 

0.50 

0.50 

8.7 

7.5 

Preventive services 

0.25 

0.35 

4.3 

5.2 

Contingent fund 

0.25 

0.35 

4.3 

5.2 

Total i 

Minimum or early year 
Maximum or later year 

$5.75 

$6.70 

100.0 

100.0 


* 


























- 76 - 


Total Cost of Benefits for Employees 

The cost estimates for the cash and medical benefits may now be 
brought together—for the limited coverage considered here (employees 
only)* Supplemented by an allowance for administration, the total 
expected annual costs may be shown as follows; 


Cost item 

Percent of 

earnings 18/ $ per insured 

Percent of 
total 

Cash benefits 

Medical benefits 
Administration (15$) 19/ 

1,30-1,72 

1,36-1.59 

0,47-0.58 

5.37-7,10 

5.75-6.70 

1.96-2.43 

a.5-44.2 
43 • 5—40 * 8 
15*0 

Total 19/ 

3.13-3.89 

$13*08-16*23 

100*0 

Cash benefits 

Medical benefits 
Administration (12-1/2$)20/ 

1.30-1,72 

1.36-1.59 

0.38-0.47 

5 ©37-7*10 
5*75-6*70 
1*59-1*97 

42.8-45.5 

44.7-42.0 

12.5 

Total 20/ 

3.04-3.78 

$12.71-15.77 

100.0 


This summary suggests that all benefits (for employees only), 
including cash and medical benefits and administration, would involve 
a cost within the range $12*70-416 0 25 P er capita a year, equivalent 
to something within the range 3 o 0 - 3<>9 percent of insurance-covered 
annual earnings* Since the higher figures in these ranges include 
some costs (especially for certain medical benefits) which are expected 
to be reached only after a few years of developing facilities and 
personnel, it is quite safe to assume that the system could probably 
begin to operate (for enployees only) with a 3-percent contribution 
rate and certainly with a 4-percent rate* 

These figures are in terms of annual current costs; they do not 
provide explicitly for the capital costs of plant, equipment, etc® 
However, in the case of medical benefit and administration costs, the 
budget items were intended to make adequate provision for maintenance; 
and the maximum figures cited would also allow for amortization of 
capital costs on a non-interest-bearing basis* This budget and 
financial analysis does not deal with the source of initial capital 
investment in plant and in durable equipment; this subject will be 
treated later* 

w See Note on page 70* 

19/ For the earliest years, this tabulation allows 15 percent of total 
cost for administration* 

20/ For years after the first one or two, this tabulation assumes a 
maximum of 12—1/2 percent of total costs for administration* 



















- 77 - 


Cost of Medical Benefits for Dependents 

The coverage of dependents has been estimated in the preceding 
notes, but has not been included in the tables which show costs applicable 
only to the compulsory coverage of employees® 

The Social Insurance Law of October 1949 and the revised draft 
bill provide that an insured employee may arrange for the voluntary 
coverage of certain of his dependants—wife or common-law wife (plac£), 
and children under 16 years of age—for the receipt of the medical 
benefits® For such voluntary insurance, the Law requires a contribution 
from the employee equal to 5 percent of his basic 'wage® 

There is no adequate body of data with which to calculate 
reliably the probable cost of medical benefits for dependents® For an 
average population of wives and children, the per-capita cost is likely 
to be about the same as for enployees (higher for wives, especially 
because of obstetrical and gynecological cases; and lower for children 
of all ages)® The estimates developed on previous pages suggest, for 
medical benefits, a per-capita cost of about l®5-2®0 percent of 
insurance-covered earnings (one-half of the cost per employee for both 
cash and medical benefits and for administration)® Until further 
informtion becomes available, it has to be assumed that there may be 
as few as 1 or as many as 2 qualifying dependents per insured employee® 
Thus, voluntary medical-care insurance for dependents might cost l o 5-4®0 
percent of basic wage (by comparison with the 5 percent rate in the law) s 2/ 

It should be noted, however, that these remarks on the contribution 
rate for dependents refer to medical benefits for an average population 
of wives and children® Since the insurance coverage of dependents would 
be voluntary, rather than compulsory, each insured employee would have 
the right to decide for himself whether or not to choose to have his 
dependents covered® With a fixed and uniform contribution rate for 
such voluntary coverage, it is to be expected that the coverage would 
be chosen disproportionately by those who decide they can afford it and 
who need it, especially by those who have a relatively large number of 
dependents, and by those who know or expect that their dependents already 
need or will need medical services® An adverse selection of risk must 
be expected for this coverage® It would result in a higher-than-assumed 
number of dependents per insured employee, and a higher-than-average 
cost of medical benefits per insured dependent. 


21/ Combined contributions for enployees and their dependents would 
then have to equal 4®5-8 percent (3-4 percent for the employee 
plus l®5-4®0 percent for dependents), instead of the 13 percent 
in the law (8 percent for the enployee plus 5 percent for 
dependents)o 








- 78 - 


Adverse selection could be so severe that the total number of 
dependents covered would be much less than the number estimated 
earlier; the number of dependents per employee among the insured 
employees who pay voluntary insurance premiums could be several times 
the ratio previously assumed; and the cost of medical benefits per 
dependent or per insured employee could be several or even many times 
the estinated premium. Even the 5-percent contribution rate specified 
in the law for this voluntary insurance could prove to be only a 
fraction of what would be needed to cover the costs for this coverage. 

Thus, it would appear that the cost of medical benefits for 
dependents to be voluntarily insured cannot be anticipated within a 
wide range of possible estirates. This suggests that such insurance— 
if undertaken at all—should be initiated only with the greatest care. 

In the alternative, if the insurance protection of dependents 
is regarded as highly important and desirable, it should be considered 
on a compulsory basis applicable to all insured employees. Compulsory 
coverage would avoid self-selection of dependent coverage and adverse 
selection of covered risk, and would give reasonable reliability to 
the cost estimateSo 

Voluntary Insurance of Employees 

The Social Insurance Law of October 1949 provides that employees 
(in insurance-covered employments) who are not compulsorily insured 
because their monthly earnings exceed 0300, may become insured 
voluntarily by electing to be covered and to pay contributions of 
6 percent on earnings up to 0500 per month. Such voluntary insurance 
would be subject to proof of absence of conditions affecting ability 
to work. 

The draft of a revised law also provides for the voluntary 
insurance of various classes of employees specifically exempted from 
compulsory insurance (family workers, aliens and temporary resident 
technicians, military personnel, and clergymen). They would be 
required to pay contributions of 6 percent on earnings up to 0500 per 
month. 

There is no adequate body of information for an estimate of 
costs for such voluntary insurance. It has to be assumed in this 
analysis that, if implemented, the administrative rules and 
regulations would assure that benefit costs for voluntarily insured 
persons would be balanced by their contributions. 



- 79 - 


Cost Effects of Certain 
Revisions in the Specifications 

Various specifications in the law, and in the revised draft bill, 
deserve review for their effects on the financial analysis,, 

Earnings Limits on Coverage 

and Contributions 


From the data at hand, it is possible to indicate the approxi¬ 
mate effects of changes in the assumed earnings limit on coverage 
(0500 per month) and on the maximum amount of earnings subject to the 
insurance contribution rate (0300 per month)*, The folloYdng tabulation 
(based on table 24 and Appendix table 17) shows the proportionate 
increase in income to the insurance fund that would result from various 
adjustments in these specifications: 


Relative Insurance Contribution Income 


(Inco 

me with the specifications used above 

= 100) 


Income limit on 

coverage Income limit on contributions 


‘ 0300/mOo 

05OO/mo o • 

None 


Port-au-Prince 


. 

0500 per month 

• 100 

106 


None 

108 

128 

141 

Both Port-au-Prince and Provincial Towns- 


0500 per month 

'• loo - 

o 

«H 


None 

107 

121 . 

132 


This tabulation shows that keeping the .limit of 0500 per month on 
compulsory coverage but making all such earnings subject to the contri¬ 
bution rate increases the estimated insurance income by 6 percent for 
the limited coverage in Port«au-Priace, and by 3 percent for coverage 
in both Port-au-Prince and the provincial towns „ A change of this 
magnitude would not substantially affect the financial analysis*, 

Dropping the 0500 per month limit on coverage (but keeping the 
0300 limit on monthly earnings subject to contribution) increases the 
estimated insurance income by 8 and 7 percent, respectively« Simultan- 

















- 80 - 


eously increasing the income which is subject to contributions from 
$300 per month to 0500 per month increases insurance income by 28 
and 21 percent, respectively; and abolishing this limit altogether 
adds 41 and 32 percent, respectively* 

It may be assumed that the risk-rates for benefits would be 
substantially unaffected by increases in the limit on earnings subject 
to contribution; and that they would be improved (i*e*, lowered) by 
abolition of the earnings limit on coverage* Thus, the net increases 
in proportionate income would be as large as, or even larger than, 
those shown in the tabulations* 

The increases in income shown above would directly affect the 
contribution rates needed to finance the insurance system* The 
effects may be illustrated by the following tabulation* For the 
limited coverage of employees in Port-au-Prince, the estimated 
contribution rates are taken at 3 * 0 - 4*0 percent (see page 76 )* 

Assuming compulsory coverage of dependents, these contribution rates 
are increased by 50 percent for 1 dependent and by 100 percent for 
2 dependents per employee, respectively, calling for 4 * 5 , 6*0 or 8*0 
percent contribution rates for the combined compulsory coverage of 
employees and their dependents* Eliminating the earnings limit on 
coverage altogether, and increasing the earnings limit on contribu¬ 
tions from 0300 to 0500 per month increases insurance income by 28 
percent; eliminating both limits increases income by 41 percent* 


Effects on Contribution Rate Resulting from Changes in the 

Earnings Limits on Coverage and Contributions 

(Limited coverage for Port-au-Prince only) 


Estimated total contribution 
rate with specifications in 
the revised draft bill 22 / 


Equivalent contribution rate 
without earnings limit on 
coverage, and with specified 
limit on contributions 
0500 per month None 


Employees only 23/ 
3o0 
4*0 


2*2 2*1 

3d 2.8 


Employees and dependents 24/ 

4o5 

6*0 

8*0 


3*5 3*2 

4*2 
5*6 



22/ Asspming a coverage limit of 0500 per month and a contribution 
limit of 0300 per month* 

23/ Conpulsory coverage. 

24 / Assuming compulsory coverage for dependents as well as for 
employees* 











- 81 - 


Ihe effects on the contribution rates are large® Employee cover¬ 
age (only) could be effected for not more than 2 0 B or 3»1 percent (i®e®, 
about 3 percent) instead of 3~4 percent® Total coverage of employees 
and dependents, with both on a compulsory basis, could be effected for 
3o2-4°7 percent, instead of 4 ® 5 “ 6 o 0 percent, if there is one dependent 
p 9 r employee| and for 4 ° 2 = 6 0 3 percent, instead of 6-8 percent, if there 
are two dependents per employee® 

This analysis suggests that careful consideration should be 
given to changes in the earnings limits on coverage and on contribu¬ 
tions, for their value in strengthening the finances of the insurance 
system, holding down the contribution rates, and enabling the provision 
of more adequate benefits® 

Specifications for 

Cash Be ne fits 

——————m m n ■—■ i f 

In the interest of making a conservative beginning, the specifi¬ 
cations for the various cash benefits might be made less generous than 
presently in the law (and in the revised draft law), and less generous 
than in the specifications previously used in this financial analysis ®257 

The eligibility conditions are moderately strict—registration 
for at least 6 months, with insurance contributions paid in at least 
one-half of the last 6 -months s period, of the preceding 6 -months* 
period, or of the last 12=months» period» For the limited coverage 
considered in this analysis, it appears that changes in these require¬ 
ments—in the direction of either tightening or loosening them—will 
not materially affect the expected costs® For a broader coverage, 
including many persons with only partial employment, the effects 
could be quite different® Consequently, no changes in eligibility 
conditions are considered here® 

The wage-loss benefits might be lowered in cost by reducing the 
benefit rate from 67 percent to 50 percent of basic wage® This would 
effect reduction in the amount of benefit paid per compensable claim 
and—because of the less attractive nature of the benefit in marginal 
cases of incapacity—in the number of compensable claims® Such a 
change in specification may be expected to reduce the cost of this 
benefit by 25 or more percent (if there is no minimum benefit amount)® 

It is safe to assume a reduction of at least 25 percent® 


257 No revisions in the medical benefits are considered here® The 
revised draft law provides that hospitalization shall not exceed 
30 days in a case, but that this period may be extended in special 
kinds of cases by administrative decision® This limitation has 
already been taken into account in the estimate of hospital 
benefit (1 day per capita per annum)® 







- 82 - 


A similar reduction in the benefit rate, for maternity benefits 
may be expected to reduce this benefit cost by about the same 
proportion— at least 25 percent© 

> * • . • 

The death benefit would be an amount* .equal to 3 months 1 basic 
wages© If reduced to 1-1/2 month's wages, the cost would become one- 
half of the amount estimated earlier ; and if reduced to 1 month’s 
wages, one-third; •*•■ 

The financial effects of such changes in specifications may 
be summarized as follows: 

Cost Reduction Reduced Cost 

Gash benefit (% of covered earnings) (£) (% of "covered earnings) 


Wage loss 
Maternity 
Death 


loO—1©25 

0 © 0 §“ 0<>22 

0©25-0o25 


25 

25 

50 

66 2/3 


0«75-0®94 
0o04-0«17 
0©13-0»13 
0©08—0©08 


Total 1©30-1©72 


0©92-1©24 
0©87-1©19 


The reduction in the total cost of these benefits is approximately 0®4- 
0 g 5 percent of covered earnings© 

Some financial Effects of Extending Coverage 

Thus far this analysis has dealt with a coverage of employees in 
and near Port-au-Prince, limited to those who are more or less regularly 
employed on a substantially full-time basis; and it has excluded domestic 
servants, agricultural employees, etc© It has dealt with what is 
probably the most favorable coverage from a financial, as well as from 
an administrative, viewpoint© 

Extension to Lower-Paid Workers 

The extension of coverage to lower-paid workers would result in 
a smaller contribution per capita from them than from the basic cover¬ 
age© Their cash benefits (being measured by reference to their earn¬ 
ings levels) would be approximately in proportion to their contributions 
if they have noimal frequencies and durations of incapacity, and if 
they have more or less continuous employment© If their earnings and 
contributions are low because of discontinuous employment or because of 
frequent or extended periods of unemployment, but if they still have 
enough covered employment to maintain their insurance rights, their 
cash benefits will have a disproportionately heavy cost© Their medical 












- 83 - 


benefits will also cost disproprotionately much (by comparison with their 
contributions) even if they need only a 'normal amount of medical 
services—because the per-capita cost of such services is no less for 
low-income than for higher income groups; and these benefits will cost 
much more if these additionally covered persons have higher-than-average 
illness rates or medical needs 0 Thus, from a financial point of view, 
extension of limited coverage to lower-income or irregularly employed 
workers should be undertaken cautiously„ 

Extension to Other Areas . 

Extension of coverage to other areas (beyond Port-au-Prince and 
its environs) would result in somewhat lower covered.,eamings and 
lower contributions per capita.o Such data as are available (see 
chapter III) indicate ,sickness rates for the provincial towns not 
substantially different from those for coverage in Port-au-Prince« 

If medical costs are lower in the provincial towns than in Port-au- . 
Prince, in approximately the same ra.tio as applies’ to earnings, 26/ 
contribution rates (percent of basic wage) adequate in Port-au-Prince 
may be expected to be adequate in other areas—especially because 
with lesser medical resources in the provincial towns there will 
probably also be lesser amounts of hospital and medical care per 
capitao 

It is possible that lower per capita medical costs in the 
provincial towns might be offset by the extra cost of transporting 
occasional patients to Port-au-Prince for services not available to 
them locally, or by the extra cost of sending occasional visiting 
specialists from Port-au-Prince 0 These possibilities do not involve 
relatively large sums and they do not invalidate the general 
conclusions o ’ 

t 

. Thus, extension of coverage to the provincial towns appears 
not to present basic financial questions; it appears rather to be 
primarily concerned with administrative feasibility, availability of 
hospital and medical resources, etc 0 


26/ In private employment, the ratio-of average earnings in Port-au- 
Prince to average earnings in the provincial towns is as 10 is to 
7; for earnings covered by the insurance specifications in the 
October 1949 Law (coverage and contributions limited by /300/month), 
the ratio is as 10 is to 9°4 (see Appendix table 17); and with limits 
of /500/month on coverage and /300/month on contribution earnings, 
the ratio is 10:8o6o In public employment (according to the . 
third survey, Appendix - -table 19), the ratio of average earnings in 
Port-au-Prince to average earnings elsewhere is as 10 is to 7; for 
earnings as in the Law, the ratio is 10s8.6; and with limits of 
/500/month on coverage and /300/month on contributions, the ratio 
is 10:8o 





- 84 - 


The Insurance Contribution Rates 

The results of this financial analysis may now be summarized in 
terms of the contribution rates required to finance the insurance 
system. ■’ * * 

\ 

lo The Social Insurance Law of October 1949 (and the tentative 
revised draft law) provide £o,r contributions as follows: 


Contribution (% of covered earnings ) 

Employee Employer Total 


Compulsory insurance of employees.•• 
Voluntary insurance of employees 
with above-limit earnings 0 ..o.•.c., 


Voluntary insuranee of employees 1 
dependents 


O o o <* • 6 .o o o o o o o 


0 0 0 0 0 9 


4 
6 

5 


4 


8 

6 

5 


2. (a) For the limited Port-au-Prince coverage, using adjusted 

specificationsj the cash benefits would cost about 1.3-1.7 percent of 
covered earnings. Plus a pro-rata store @f administrative costs, they 
would cost about 1.5-2 percent of earnings. 


(b) The medical benefits, for this limited coverage, would 
cost about $5.75-$6.70 per capita 0 With administrative costs added, the 
costs would be about $6.60-$7.70 per capita. 


3o With the coverage specified in-the Social Insurance Law of 
October 1949 (compulsory coverage of workers with earnings up to 0300 per 
month, and contributions on amounts up to 0300 per month), the average 
insurance-covered earnings would be about $373 per capita in the Port-au- 
Prince area 0 The costs cited in par. 2 would then be as follows; 


Cash benefits (/ 
Medical benefits 

Total.... 


a dmi iio)oo.o©.o 
(/ admin.).... 


$/cap. 

5o60- 7 o 46 
6o60-"7.70 

12.20-15ol6 


% of earnings 

1 o 5-2 . 0 
1o 8-2 o1 

3*3-4.1 


Thus, with these specifications on coverage and contributions, 
the contribution rate would need to be about 3.5-4 percent for this 
limited system. 

t 

-a 4. With the coverage specifications used in this financial analysis, 
and in the revised, draft law, the compulsory insurance would cover workers 
having earnings up to 0500 per month, and contributions would be payable on 
am®unts up to 0300 per month. The average covered earnings would be about 












- 85 - 


$413 per capita,, The costs cited in par« 2 would then be as follows: 

—f/capo 1 of earnings 


Cash benefits (/ admin,) . 0 o. 
Medical benefits (/ adraino) 


00000*00 


Total 


oooooooooo oooo 


ooooooooo 


0 0 0 0 * 0 0 


6,20- 8,26 
6o60~ ? P 70 

12,80-13.96 


1,5-2,0 
1q 6-1 q-9 


3 o1-3 o9 


Accordingly, the contribution rate would need to be about 3-4 
percent, and a rate of 4 1/2 or 5 percent would be ample or generous, 


5o If compulsory coverage for the Port-au-Prince area is 
extended to all employees in covered employments, regardless of earnings, 
and if earnings up to 05®O are made subject to contributions, the 
insurance income is increased about percent above what it would be 
with the specifications in the Law, with such revised specifications, 
the average insurance-covered earnings become $528 per capita, and the 
costs become as follows: 


l/gap^ 


% of earnings 


Cash benefits (/ admin 0 }c .„., 0 •.... 0 7.92-10„56 
Medical benefits (/ admin,). .,•....• 6o60- 7o70 


Totalo.o 




o o 


ooooeoo*** 


14o52-18o26 


Io5-2c0 

1o3-1q5 


2 o8-3 o5 


With these specifications, the contribution rate needs to be in the range 
2,8-3o5 percent; 3°0 percent could be ample for the first few years, and 
4 percent would be ample even in later years when medical personnel have 
been increased and medical facilities have become much more adequate« 

A 4-percent contribution rate would enable the insurance system to 
accumulate st»me reserve capital, and to make investments in capital facilities 
useful to the insured e 

6o With revisions in the specifications for the cash benefits, 
as cited on pages 81 to 82 , the cost of these benefits could be 
readily reduced by one-fourth to one-thirdo The total cost of all 
benefits would be reduced by about Oo4-Oo5 percent of earnings. Thus, 
the costs would be qs follows: 

In par, 3°.*. 2o9~3°6 

" " 4oo.o 2o7-3o4 

" " 5oo.o 2o4-3o0 


With such adjustments in the insurance specifications, the contribution 
rates could be reduced accordingly» 











- 86 — 


7o All of these analyses are based upon fragmentary data and 
rely on assumptions which have many uncertainties 0 Also, lacking 
insurance experience, data, skilled personnel, etc 0 , it is important 
that the financing start on a conservative' basis o In addition, when 
finally selecting a contribution rate, a substantial margin of safety 
must be allowed because these calculations have been made on the basis 
of estimated average annual earnings which coiild > prove to be somewhat 
too high for forecasting insurance income (See Note on page 70) • It is 
clear, however, that an insurance system -of limited coverage in the 
Port-au-Prince area, for employees only, could have specifications 
which would not need contributions at any rate higher than about 4 per¬ 
cent of insurance-covered earnings 0 This is one^half the rate (S percent) 
Specified in the Law of October 1949. 


8o There is no valid basis at this time for a financial analysis 
applicable to voluntary insurance of either employees who are not 
compulsorily insured or of dependents of compulsorily insured employees. 
The analysis suggests, however, that the cost of compulsory coverage of 
dependents (for medical benefits only) can probably be estimated with 
reasonable reliability, With the conservative assumption of 2 eligible 
dependents per employee, the compulsory insurance of both employees and 
dependents would cost as follows: 

With the specifications 

in par, __ % of earnings 27/ 


3 

4 

5 

6 


o o o o o • ooo 

ooo*oo*o« 

OOOO oo ooo 


• o 

o o 

o o 

• o 


6o9-So3 
6 o3-7o7 
5o4-6o 5 
5 <.0-6o0 


Thus, depending on the earnings specifications for coverage and for 
contributions, and on the specifications for the cash benefits, the 
compulsory coverage of both employees and their dependents could be 
achieved for contributions at the rate of 8 1/2 percent or less—even 
for as low as 5 or 6 percent of insurance-covered earnings „ And if 
further surveys should show that is unnecessary to assume as many as 
2 dependents per compulsarily-insured employee, the contribution rate 
could be still lower» 

9. The contribution rate cannot be safely estimated from 
available data with respect to the coverage of groups like domestic 


3/ In each case , the figure here is the cost of all benefits for the 
employee plus twice the per-capita cost of medical benefits. 










- 87 - 


servants, agricultural employees, family workers, etc„ Further surveys 
and studies are needed<, 

10c Extension of coverage to the provincial towns and their 
environs can, apparently, be safely undertaken at the same contribution 
rates as are estimated for the Port-au-Prince area Q 

Equity in the Employee ? s Contribution 

It is a common rule in social insurance? that--insofar as practical— 
compulsorily insured employees as a class shall receive at least their 
money’s worth in benefits as a return for their own contributions, and 
that this relationship shall apply to all income levels among the 
insuredo In other words, the social insurance system should do at 
least as well for the insured persons as they could do for themselves 
with their own money» 

This rule of equity should be tested for any set of specifications 
finally adoptedo A single test will illustrate the method, taking what 
may be the most extreme practical example» 

Let us assume that compulsory coverage applies to all employees 
in covered employments, without regard for earnings; and that earnings 
up to 0500 per month are subject to insurance contributions,. The 
analysis presented earlier suggests that, with these specifications^ 
the costs of the benefits would justify a contribution rate of 3, 3 1/2 
or 4 percento Let us assume the highest of these rates (4 percent), and 
assume further that the employee contributes one-half (2 percent). The 
maximum contribution he would make if he had earnings of 0500 or more 
per month throughout the year is 2 percent of $1,200 (06,000), or 
$24 a year„ 

Such an insured employee would receive wage-loss protection or 
benefits that would be proportional to the earnings on which he pays 
contributions o These benefits have been estimated to be worth lo5- 
2„0 percent of his earnings 0 28/ If these benefits are worth as much 
as 2 percent, he already has the total value of his own contributions, 
without counting the value $f the medical benefits» If the wage-loss 
benefits are worth only lo£ percent, the medical benefits have to be 
worth only 0„5 percent ttf^ba'iance his accounto In his case, 0o5 
percent of earnings subject to contributions equals $6 a year„ Since 


2g/ Since the individual can have wage-loss prptection only on an insurance 
basis, the cost used here includes the expense of insurance administra¬ 
tion o 





- 88 - 


the estimates show that the ipedieal benefits wou4$. beworth $5o75”^6»70 
a year,29/ his account is balarnb^d and he has 1 an e'quJitable return fdr • 

. his contributions. . ' ‘ ' 

; • l • % ’■ ’ ' " ' 

The equity analysis would obviously be much more favorable if less 
than 4 percent total, Contribution were assumed in the illustration or if 
the employee paid less than one-half the 4 percent contribution rate. 

And obviously the tt break-even rt point is more secure for persons with 
earnings below the maximum earnings subject to contributions. The 
contributions paid by employers (or the Government, or both) balance 
the better-than-even return for employees with earnings below the maximum. 

A similar analysis should be made periodically for an operating 
system; and the limit on earnings subject to contributions, and the 
contribution rate, should be subject to change wheh the value of the 
benefits justifies or requires . 

• . *■ r » 

Allocation of Costs 

• » 

1 This financial analysis has been concerned with total costs and 
their relations to the earnings of the insured employees . It has not, 
tf»us far, dealt with the subdivision or allocation of contributions 
between employees and their employers, or between these two groups and 
the Governmento 

The Social Insurance Law of October 1949 specifies that the 
contributions of 8 percent of basic wages for the compulsory (sickness 
and maternity) insurance of employees shall be allocated equally between 
the employees and their employers (except that the entire 8 percent shall 
be a charge on the employers in respect to employees with a basic wage 
of less than jZrtLfLO per month) * It also specifies that there shall be a 
subsidy from the Government, in an amount to be determined at some 
future time . 


Social insurance practice in other countries provides no single 
or sure guide for the allocation of costs or contributions in Haiti. 

Diverse practices have evolv'e'd and are followed elsewhere. However, it 
is quite comnon for the cpsts to be shared not only by employees and 
employers, but a'lsdk by the Government. Three reasons are especially 
common and prominent in expikining and justifying Government contribu¬ 
tions, and all three apply in Haiti: (1) A sickness, maternity 
insurance relieve^ the Government of costs it would otherwise incur, either 
for income assistance to incapacitated workers and their dependents, or 


"g f " h ’ V 


2ty Here the cost of me died! benefits is exclusive of the cost of 
administration. 




- 69 - 


for their medical care; ( 2 ) such an insurance system contributes to the 
general welfare and deserves general support and financial subvention 
from the Government 5 and (3) employer contributions according to payrolls 
and employee contributions according to earnings tend to be economically 
regressive, especially to the extent that the former are passed on to 
consumers in the cost of consumption goods and the latter are paid by 
low-income workers, and such contributions should be held to a minimum 
in a non-inflationary stage of an economy. 

Haiti should therefore consider Government sharing of the costs 
of this insuranceo If it follows the practice in many other countries, 
it will contribute annually at least an amount equal to the cost of 
administration, and in addition it will share the remaining cost with 
employees and employers „ If the Government is prepared to contribute 
more than the cost of administration, it may assume responsibility for 
something like one-third the total cost, so that the contributions are 
equally divided among the l&ree sources of revenue. Or, the Government 
may consider contributing annually an amount equal to the costs of the 
medical benefits and their administration<> 

Many other proportionate allocations of the costs may be considered. 
These few seem especially pertinent to the circumstances presented by the 
program for Haiti» Whatever the decision about Government subvention, 
there is great advantage to the insurance program in having a definite 
determination in advance, so that the insurance administration knows upon 
what financial resources it can count 0 

Source of Funds for Construction of Facilities 


The focus of this analysis has been on the current costs of 
insurance benefits and administration; capital costs for the construction 
of needed facilities have not been considered 0 

Whether the insurance program is small or large, it must have 
administrative facilities„ It may obtain these by cost-free provision 
from the Government, by rental, or by ownership through purchase or 
construction Also, depending on the method used in providing hospital 
and other medical benefits, it may be concerned only with paying on a 
current-cost or reimbursement basis for hospital and medical services 
provided by or through another agency or agencies; or it may in greater 
or lesser measure have to provide for the construction of hospital and 
clinic facilities needed (and not available) for the provision of 
benefits to insured persons„ 

c . ' 

According to the Social Insurance Law of October 1949 (Article 85), 
IDASH comes into possession of all resources formerly owned by the 
Social Insurance Fund created by the decree-law of May 17, 1943° These 



- 90 - 


a6 reported consist of $50,000 in Government bonds and about $100,000 
in other property. Obviously, IDASH could not undertake the construction 
of major administrative, hospital or clinic buildings with these limited 
resourceso Moreover, these funds should be carefully husbanded as a 
reserve against the uncertainties of income and costs in the first years 
of social insurance operation 0 

According to the Law of October 1949, IDA.SH may direct that the 
payment of contributions shall begin 6 months before benefits become 
available. If it does, so direct, it can collect a reserve equal to 
one-half of a year ? s income—somewhat more than one-half' of the 
estimated annual cost of operations. This also would be a relatively 
small reserve, and it should be conserved as a cash reserve against the 
uncertain finances of the first years rather than be invested in con¬ 
struction of facilities. 

If it has to meet capital costs, IDASH should at the outset turn 
to other sources. Needed-capital funds might be a gift from the Govern¬ 
ment—a subsidy toward implementing a program which promises to make a 
substantial contribution to the general welfare. 1 Or such funds might be 
obtained by borrowing, with the future resources of IDASH serving as the 
security behind the loans and—if feasible—with the*Government itself 
guaranteeing the loans. Or part of the capital need might be met by 
gift from the Government, and part by Government guaranteed loan 
negotiated by IDASH.« Such guarantees from the Government would be 
consistent with the practice in many countries in which the Government 
guarantees all the obligations of the social insurance program by under¬ 
writing both the finances of the benefits and the security of the 
principal and interest of invested insurance reserves>and capital loans. 

v - • »«• 

Total Coverage and Finances 

It has presumably been made amply clear that the. sickness and 
maternity insurance should be developed .in‘stages, over; a. period of* 
years. At this time, it is impossible to make any reliable estimate 
of the eventual coverage and finances. 

» •• 

The limited coverage which the insurance might have at first 
in Port-au-Prince has been estimated at about 15,000 employees. And 
this number might be supplemented by 15,000-30,000 dependents if or 
when coverage and benefits are extended to them. With a contribution 
rate of about 4 percent, employee coverage would involve insurance 
operations of about $265,000 a year. With dependent as well as employee 
coverage, the total may be in the range $400,000-$530,000 a year. 



- 91 - 


Further extension of coverage in the Port-au-Prince area to 
employed groups not included above may double the coverage and increase 
the dollar amountB by one-half or more again/ Thusj the total in the 
capital area may come to have a coverage of 60,000-90,000 persons 
(employees and dependents) and to involve $600,000-^1,000,000 a year. 

No reliable data are available to estimate the results of 
corresponding extensions of- coverage throughout Haiti 0 : At a rough 
guess, the coverage may become 5*-10 times that of the Port-au-Prince 
area (300,000 to 900,000 persons). The dollar amounts involved would 
presumably be somewhat' less than propbrtionalo The over-all magnitude 
could then be operations involving as a minimum about $2.5 

millions and as a maximum about $10 millions a year, 

• * « 

Reservation 

This section must end on a cautionary note. Although emphasized 
repeatedly, it needs again'to be said that this financial analysis is 
based upon fragmentary and inadequate information and data 0 The results 
are not to be regarded as wholly reliable 0 Factors of safety have been 
used at many points, and it is possible that the costs are over- estimated. 
Nevertheless, further protection of financial balance may be necessary. 
IDASH might be authorized to make reasonable changes, with the approval 
of appropriate reviewing officers of the Government, in contribution and 
benefit'rates within prescribed limits of time and amount and on the 
basis of cumulating actual’experience. Also, the uncertain finances of 
the insurance system, in the initial years, might be protected by 
Government guarantee,. 




- 92 - 


,> • . • -CHAPTER VI • ; >■' — ' 

• • v Work'Accident Insurance * v 

!-* ‘ Si 

S •. ••• 

. . Introductory Note 

Haitian law provides various protections for the employee, and 
places various obligations and liabilities upon the employer,, The.follow¬ 
ing deserve special-^mention here, even though some of them have collateral 

rather than direct bearing on-work accident insurance— 

■ . * »• • . • ‘ * ' • ► • . 

lo The minimum age for Employment is 12 years (Law of July 25, 

1947, - art. 3)» Minors between 12 and 18 years of age'- must obtain an 

employment certificate ( permis d*emploi ) -from the Bureau of Labor before 
beings employed., ‘'An employer who hires-such a minor without the required 
certificate is subject to a fine-of 010 to 0100 ($2 to $20)'for each 
offense 0 ..... 

2. The - minimum wage for all employed- persons, ’ except domestic 

servants, is 03.50 ($0.70) per day. ' ’ *; . , 

3. The n&ximum work week is 6 days; and the maximum regular 
work day is 8 hours. Employers and employees may agree upon the length 
of the work day up to a maximum of 10 hours, but the regular work week 
may not require more than 48 ‘ hours per we eke There is no limit on 
overtime; but the rate of pay for overtime, including Sundays, may not 
be less than 150 percent of the rate'for regular work time. 

4o According to the Civil Code (arts. 1168, 1169) every person 
who by his fault causes damage to another is obligated to make repara¬ 
tion—whether the 'damage results from imprudence or negligence or 
from an overt act. Determination of reparation, damages, etc., is 
left to the discretion of the court, having regard 'for circumstances, 
fault, negligence, etc. The broad obligations of employer' 8 s liability 
arise under these provisions of the Civil* Code 0 

I • ... . > , • • " : * •' - » 

5o There is no provision in the labor laws.(except in the 
Social Insurance Law of October 1949) requiring the reporting of \ 
accidents. Various employers on occasion voluntarily make such reports 
to the Bureau of Labor. 

, 6. Every employer having 100 or rapre workers in his establish¬ 

ment, is required (Law of August 10, 1934, art* 19) to. provide and 
maintain a dispensary., protect the. health’of his employees, and furnish 
necessary care in accidents. 

. ,, . 

7. In case of sickness, an employee is entitled (Law of May 5, 

1948, arts. 10, 11) to 15 days of paid sick leave or paid maternity 
leave in a year, after one year of employment with the employer. A 
physician* s certification of incapacity may be required by the 
employer. 





- 93 


Thus, with respect to work accidents and injuries, employers 
have broad legal obligations and liabilities for the consequences of 
work accidents and injuries 0 It is well-known, however, that in 
actual practice these obligations and liabilities are unevenly 
observedo Indeed, there are apparently reliable reports that many 
employers honor them as much in the breach as in the observance 0 

It is reported that many employers with relatively small 
establishments pay lower wages than the larger employers, are not as 
effectively supervised by the Department of Labor, do not so frequently 
or regularly provide medical care to or for injured workmen, and do not 
so systematically pay wages during periods of sickness or work-connected 
disablemento Many employers, large and small, are said to follow the 
practice of dismissing employees who become sick and of replacing them 
with others—a practice which is rather easily followed because of the 
large numbers available for employment 0 

Contrariwise, many employers meet—and some more than meet— 
their required obligations, paying full wages during short periods of 
incapacity and from one-half to full wages during long periods, and 
making substantial settlements in cases of permanent (total or partial) 
disablement or of death 0 

Some employers tell shocking accounts of the evils of settlements 
through lawyers in work-injury cases, especially with reference to how 
large a share of the settlement money fails to reach the injured worker 0 
Employers quite generally indicated they would be glad to have an orderly 
system of compensation, with concomitant relief from employer liability, 
disputes and actual or threatened law suits„ 

Various observations and reports indicate that most employers 
carry their own risk for their liabilities in case of work-connected 
accident and injury, and do not rely on insurance—^except as they are 
self-insurerso This appears to be quite generally the case for 
employers operating small, medium and large establishments» In the 
Port-au-Prince area, a canvass of 30 medium and large employers found 
only 4 with formal insurance or employee-benefit provision (3 with 
commercial insurance contracts and 1 with an employer-administered 
disability plan) to meet work-accident and injury liability „ 

A review of the existing situation endorses the Government's 
intention to establish a comprehensive and orderly system of compensation 
for work accidents and injuries 0 The outlook for increasing industrializa¬ 
tion and agricultural employment in Haiti reinforces the wisdom of this 
conclusion 0 The problems focus on ways and means 0 

Major Specifications for Work Accident Insurance 

As indicated in chapter I, the Social Insurance Law of October 
1949 proposes to establish a system of workmen's compensation<> With 



- 94 - 


* i • • 

certain stated exceptions, it would apply to all public employment; • 
and to employers in industry, commerce, private teaching, domestic 
service and agriculture; and it would cover all employees in 
establishments to which the law applies, regardless of the amount of 
£he employee’s individual earnings and whether he is a manual or a non- 
manual worker„ It would require employers to report all accidents 
involving incapacitation of one day or more 0 It would Obligate IDASH to 
provide or pay various benefits— • 

(1) Comprehensive medical benefits until recovery : 

(2) Cash (wage loss) benefits — 

(a) Temporary disability ; from the fourth day of 
incapacity, at the rate of 50 percent of basic wage 
plus 10 percent for each dependent, up to a family 
maximum of 70 percent; 

(b) Permanent total disability : pension at the rate of 2/3 
of basic wage for the duration of the disability; 

't 

(c) Permanent partial disability : pension in proportion %p 
the degree of disability, with lump-sum settlement in 
cases of less than 25 percent disability; 

(d) Death benefit : (1) Lump-sum equal to one-month’s basic 
wage; ( 2 ) pension for the widow at the rate of 50 percent 
of the permanent total disability pension (at the rate of 
30.percent to the non-legitimate spouse), and pension for 
each child,, at the rate of 20 percent of disability pjgnsion 
with a family'maximum equivalent to 80 percent of 
disability pension 0 

For this system of benefits, the law requires an initial contribu¬ 
tion at the rate of 1 percent of basic wage, with authority that the 
rate may be modified upward and downward by IDA.SH on the basis of 
experienceo The contribution is to be paid wholly by the employero 

The provisions of the Law were reviewed in detail with officers 
of the Governraento Various amendments were considered, including: more 
precise description of coverage; inauguration of the system in stages; 
revision of benefits with regard for adequacy and for simplification of 
administration; and clarification of employer obligations and relief 
from employer liability c 









- 95 - 


Special Problems of Administration 

The inauguration and operation of workmen's compensation presents 
many difficulties in Haitio Some of these were mentioned (chapter II) 0 
As in the case of sickness and maternity insurance, the greatest 
difficulties result from lack of experience in social insurance 
administration and of trained administrative personnel, unfamiliarity of 
the public with social insurance, and inadequacy of resources for 
provision of medical benefits <, 

In this connection, it has been pointed out that application of 
the insurance will be difficult in the case of medium and small 
establishments—particularly agricultural establishments—in remote 
placeso The difficulties will be multiplied, it is said, with respect 
to the seasonal and casual employees of large or small agricultural 
establishments because of the very high rate of turnover, absence of an 
adequate system of identifying individual workers, aind the common 
practice of sub-contracting so that the employer has no direct relation 
with many of the farm employeeso These anticipated difficulties have 
led to proposals that the insurance should not be extended to 
agricultural employments until after it has become well established for 
commerce and industry and administrative experience has been accumulatedo 
It has also been proposed that agricultural coverage should be limited 
to the regular (office, factory and farm) employees and should exempt 
the irregularly employed farm laboro But this, it is recognized even 
by those who suggest it, would exclude workers who very badly need the 
insurance protect!on» It is not a preferred solution., 

Development in Stages 

As in the case of sibkn'ess and maternity insurance, there would 
be many advantages in developing workmen's compensation in stageso For 
example, as a first step it might advantageously be initiated in Port” 
a*u-Prince and its environs, involving the establishment of only a 
central administrative office, a small staff, a localized educational 
program for employers and employees, and a system for provision of 
medical benefits in an area where the hospital and medical resources 
(however generally deficient) are nevertheless the most extensive in 
Haitio Then, after a suitable period of actual experience with 
administration, the coverage might be extended to other areas, with 
local administrative offices organized through the use of personnel 
trained in Port-au-Princeo On this pattern, initial coverage might 
apply to coiamsrce and industry—whether or not it also applies to 
domestic service; agricultural coverage might be undertaken at a later 
stageo 




- .96 - 


Development of the insurance in successive, delimited, 
geographical areas would result in non-uniform treatment of employers 
in a particular field of enterprise, according to their location, in 
the period between inauguration of the system and its national 
application,, It is supposed that this is not a serious objection 
against geographical gradualism because workmens compensation replaces 
and supersedes employer liability; and the employer in one area who 
is not covered by the insurance carries the cost of employer liability, 
ihile a comparable emplo^frr u)io is covered carries the cost of the 
iifeuranceo Nevertheless,•suc% differences should obviously be 
eliminated as rapidly as possible„ In other words, the inauguration 
of the insurant© should be pleaded by as much preparation as possible 
for its application throughout the country; and its inception in a first 
area (e 0 g 0 , Port-au-Prince^bhould be followed as rapidly as possible 

by its establishment in otner areas and throughout the country „ 

v 

The availability of rescan* ces for the medical benefits, and the 
rapidity with which arrangements can be made to ensure the availability 
of these benefits to injured employees, will in large measure determine 
the rate at which the insurance can be undertaken. If HASH should 
decide that these benefits are to be furnished by the Department of 
Public Health—through its hospitals, clinics and staffs, according to 
contract between the Department and IDA.SH, this may properly influence 
the plan for the geographical extension of the insurance „ The public 
hospital and clinic system, maintained by the Department of Public 
Health, operates through a series of hospital districts, with a general 
hospital as the basis for the facilities and resources in eacho The 
insurance system may derive many advantages from being implemented 
successively in areas which coincide with these districts» 

Limited Coverage in Port-au-Prince . 

It is estimated that if an initial coverage were restricted to 
the Port-au-Prince area and applied only to public employment and to 
conmerce and industry, it might include about 16,000 persons on an 
annual basis—perhaps 20,000 or more different persons in the course of 
a year 0 The average earnings per employee covered (at 1949-50 levels)’ 
would be about $710 a year for public employees, about $450 a year for 
private employees, and about $550 a year for bothol/ Thus, this 
limited insurance operation in this area would cover total payrolls 
amounting to about $8,800,000 a year,, If the insurance premium is 
initially 1-2 percent of covered payroll, the insurance operations would 
involve about $88,000-$176,000 a year,, This is a very small sum to 

1/ These average annual earnings per covered employee are higher than 
the corresponding figures for sickness and maternity insurance 
because there would be no ’’ceiling” on earnings covered by workmen's 
compensation,. See table 24 and Appendix tables 17, 18 and 19 „ 





- 97 


permit or support an efficient administrative organization of the kind 
that would be involvedo It would demand efficient administration to 
make the operation possible, while keeping initial administrative costs 
within such a range as 10-20 percent of total disbursementso 

If the initial coverage includes domestic servants, the 
employee figures cited in the preceding paragraph would presumably 
be increased by about 30-50 percent for coverage and about 20-35 per¬ 
cent for insurance contributions „ 

If the limited coverage is initially applied to the Port-au- 
Prince hospital district, the coverage would probably be increased by 
another 30 percent, and the contribution income would be increased 
somewhat less than proportionally*, 

Extension of the coverage throughout Haiti may be expected to 
increase these figures 5-10 fold, and to permit reduction in the 
percentage of total disbursements used for administration*, 

If such an ^initial system is too small for efficient or 
effective operation within its current financial resources, lack of 
necessary administrative funds should not be permitted to stand in 
the way of the undertakingo A substantial part of the administrative 
cost to be incurred for the initial organizing and operating experience 
should be regarded as a developmental cost for the whole national 
system of workmen’s compensation 0 Such a developmental cost may 
properly be met by the Government out of general revenues, may be 
financed by IDASH out of its initial reserves, may be incurred as a 
debt to be amortized out of future income, or may be distributed among 
several such sources of funds„ 

The Contribution Rate 

There is no adequate body of information on which to base an 
altogether reliable estimate of the contribution rate needed for 
work-accident insurance,* or an altogether reliable evaluation of the 
rate specified in the Law e Analysis must depend on fragmentary data 
available in Haiti, and on information derived from experience in other 
countries which have workmen’s compensation more or less similar to that 
proposed by the Haitian Law 0 

In general, it is expected that, for similar benefits, the cost 
of work-injury benefits (per employee or per $100 of covered payroll), 
and the contribution rate, would be lower than in most other countries *2/ 
The reason for this is that, in general, there are few industries in 
Haiti that are even moderately hazardous, and fewer if any that are 

2/ Social Security Throughout the World , Bureau Report No„ 16/ Division 

of Research and Statistics, Social Security Administration, Washington, 
1949. 






- 98 - 



very hazardous—in the sense in which these terms are used in more 
highly industrialized countries.- There is little or no employment 
in Haiti which, with respect to frequency or severity of work injuries, 
would be classified with such highly hazardous industries as sub¬ 
surface mining, dusty quarrying, high-building construction, tunnel 
digging, etc., common in the U.S.A. and other countries. 

v « 

• - • » - i 

The farming and factory work of large agricultural establishments 
(sugar, sisal, etc.) probably represents the most hazardous employment 
of substantial size in Haiti.< A number of such establishments were 
visited—to observe them in.operation, to learn about their employment 
arrangements and provisions for the care of injured workers, and to 
get some impression of their work-injury risk-rates and costs. Some 
of them are apparently incurring costs, for compensation and care of 
injured employees, in the.range 1-1.5 percent of payroll (see Appendix B ). 
The compensation payments and medical benefits are reasonably similar to 
those proposed for work accident insurance—though more generous In 
some respects and less in others. 

As against. relatively hazardous agricultural employment,^work 
injuries are apparently much less frequent 1 and expensive in most 
i. industrial, establishments- or public employments, ( and.still less frequent 
or costly in conmereial establishments (business offices, wholesale 
and retail trade, etc.). *• * 

So far as has been ascertained, the few large industrial 
employers in Haiti who ( insure their work-accident risk through an 
independent* (commercial) insurance carrier pay, premiums of 0.75-l<=25 
percent of payroll or less, j depending on the company, establishment, 
etc 0 Other medium and large businesses, with'lower risk rates, 
generally operate as -self-insurersv A total’ cost* as low as 0.4 percent 
qf payroll is reported by a ! large industrial' establishment which 
sustains a good reputation for meeting its obligations with respect to 

work injuries. „ 

. 1 > . , . * 

*> 

It is recognized that costs below 1.25 or 1 percent of payroll 
being incurred'iji some establishments do not necessarily reflect what 
-the costs should or might- be 3 they reflect a mixture of this and of 
current failures to pay adequate compensation, and u of neglect’in ' 
providing such care as would represent a proper, discharge of the 
employer ^ 1 liability. 

The benefit specifications in the Law of October 1949 are 
comprehensive, and in some respects relatively generous. The system 
would; have to*be inaugurated with much uncertainty about the cost, 
because ,nq adequate experience‘s da^a are available to provide a 
reliable ‘guide. It would therefore be advisable to make the benefit 



- 99 - 


specifications as conservative as social adequacy permits, and to allow 
for administrative adjustments—on the basis of experience--both in 
certain benefits and in contribution rates. 

Having regard for existing conditions and practices, and for the 
lack of accurate, comprehensive or adequate data, it would appear that 
if workmen’s compensation is undertaken it might consider using 
financial specifications like the following— 

(a) Require initial uniform contributions from covered 
employers at the rate of 1 percent of total payrolls, 
and begin collecting such contributions for an advance 
period of perhaps 6 months before benefit obligations 
become effective; 

(b) Authorize that retroactive changes in this contribution 
rate may be imposed for the first benefit year, or for 
the first two (or possibly three) benefit years, but only 
on the basis of necessity dictated by actual accumulating 
experience under operating conditions. Such retroactive 
changes by administrative decisions might be permitted to 
increase this rate to a maximum of (say) 2 percent; 

(c) Authorize that the rate for subsequent years may be 
uniformly at a higher or lower rate as experience indicates 
is necessary; or that the applicable rate may be graduated 
for all employers and/or separate establishments on the 
basis of actual risk and benefit experience. 

» 

Graduation of the Contribution Rate 


The alternative use of uniform or graduated contribution rates 
deserves some further discussion. 

In some countries, insurance against work accidents and injuries 
(workiren’s compensation) uses an average premium rate and applies it 
uniformly to all covered employers; in other countries, the rate is 
adjusted for each major industry according to insurance experience. 

Where adjusted premiums are used, an industry which has a high 
accident rate, or one in which serious and costly injuries are relatively 
frequent, is assigned a higher-than-average premium rate. Correspondingly, 
an industry with relatively low benefit costs is given a less-than-average 
premium. Such ’’manual'’ rates are revised periodically in light of 
actual experience. 



- 100 - 


In addition, it is not uncommon to have individual employer "merit 
rating"; the nremium rate for each employer in an industry is adjusted 
according as his experience is more favorable than that of the industry 
as a whole * or is less favorable* 

In some countries, manual rating is without arbitrary limit on 
the size of the premium rate. With an average rate of (say) 1, 2 or 3 
percent of payroll, the manual rate for an employer with very low 
frequency or severity of injuries—at the one extreme—may be only a 
small fraction of 1 percent (e.g., 1/10 or l/20 of 1 percent for office 
workers only); at the other extreme, the rate for a highly hazardous 
industry (like quarrying, blasting, underground mining, etc.) may be 
10, 20 or more percent of payroll. In other countries, the industry 
rating is bounded by fixed percentages of payroll or by fixed percentages 
above or below the average rate for all industries. Where individual 
employer merit rating is also used, it is usually kept within fixed 
limits, e.g., 20, 25 , 33 1/3 or 50 percent above or below the rating for 
the industry. 

The main purposes of such experience rating are, first, to 
place the cost of the insurance where the costs are incurred (i.e 0 , 
to make the cost of work injuries a cost of doing business); and, second, 
to provide a financial stimulus for the promotion of safety programs 
and the prevention of accidents. In greater or lesser measure, these 
rating procedures achieve both purposes. But they also, in some measure,tax! 
to defeat the general social purposes of the insurance, especially where 
they may place a prohibitive cost on an essential industry or severely 
affect the costs of products essential to the econony. A moderation of 
experience rating is therefore often practiced (as noted above) by 
arbitrary limits on the range of the premium rates, or by Government 
assumption of the cost of administration and/or of part of the total oust 
of benefits. Also, in some countries the premiums for workmen's 
compensation are pooled with the premiums for other social insurances, 
so that the total costs are uniform percentages of payroll in all 
industries covered by the insurance system. 

With highly variant practices throughout the world, there is no 
single or sure guide for workmen’s compensation in Haiti. It may adopt 
a uniform rate for all industries and all employers; it may decide upon 
fully graduated premiums according to risk; or it may adopt a compromise 
between these extremes. 

If Haiti establishes workmen’s compensation, it would start with 
little substantial experience in this field. It should therefore 
inaugurate its program with a plan which is adapted to its own 
circumstances and needs. 


* 101 - 


As suggested above, it would probably be wise for Haiti tostai# 
with an initially uniform premium -rat’e for a* first contribution period 
with provision for subsequent adjustment of^th'is •rate by retroactive'’’ 1 
assessments on the basis of experience<> And this process might be 
repeated for a second or third year* If total costs in a year are found 
to exceed the income from such an initial rate (with allowance for 
benefit obligations incurred for payment in future years), these assess¬ 
ments might be on a uniform basis, or they'might be graduated according 
to risk* Uniform rates for such a period would be unquestionably simpler 
to determine and assess? graduated rates would have only meager basis 
in experience o But being retroactive—and, in such an initial period, 
being without full fore-waming to the employers, such assessments might 
properly be limited in range. For example, the 1 retroactive assessments 
might be limited to (say) a maximum of 100 percent of the initial rate 
(uniform or average). Such a practice, or an adaptation of it, might 
be followed for the first years. Then, when experience indicates a 
better course, premium rate-making and rates might be fixed on a more 
permanent basis. 

Exemption of Small Establishments 

■*l’* 

It is not uncommon for workmen’s compensation (or other social 
insurance) to exempt from coverage small employment establishments for 
reasons of administrative convenience and economy, and because of 
difficulties in effecting compliance with the law from such establish¬ 
ments. Observation in Haiti does not suggest the need for this, except 
perhaps in the case of agricultural establishments—to exempt (say) 
those with fewer than some such number as 5, 4 of 3 employees at any 
time. 

Self-Insurance and Contractiyg-Out 

Many workmen’s compensation systems permit employers, especially 
those with a substantial number of employees, to operate as self- 
insurers or to insure their risk with an independent insurance carrier; 
and some systems use these methods in competition with a state insurance 
fund, or use them exclusively. In actual practice, both self-insurance 
and contracting-out generally operate for the better-than-average risks; 
and where practiced in parallel with a state fund (which has to insure 
any covered employer who applies), they inevitably operate to*‘leave the 
state fund with the poorer risks. Such adverse selection against^ the 
state fund could be very serious—or even disastrous—for 1 such a small 
system as might be established in Haiti. And both self-insurance and 
contracting-out could make the residual coverage too small for practical 
operation. Some employers proposed that these practices.be permitted 
but did not urge them when the objections were cited; other employers 
neither proposed nor advocated them. 





- 102 - 


CHAPTER VII 

■. r , 

• Medical • Benefits' ’• in’ Port-au-Prince 

Previous discussions have' indicated that the social insurance 
♦program might' start with limited‘coverage' in the Port—au—Prince area* 

Tfthat would be *the magnitude • of- the' obligations for medical ’benefits— 
whether the services'are provided by IDASH itself, through the Department 
’of'Public Health, or* otherwise? 

> i t 

* * . , . 

The following estimates are based on the coverage figures and 

the earnings levels of 1949-50. 


Coverage 

The estimates recapitulated here apply only to the limited 
coverage in Port-au-Prince, previously used (chapters V and VI) as a 
first benchmark for analyses of coverage, benefits and costs— 


Private employees.10,000 

Public employees. 6,000 

Total employees. 16,000 

Number to be entitled to workmen’s 
compensation benefits. 16,000 l/ 

Number qualifying for sickness and 
maternity insurance medical benefits: 

Employees.15,000 

Dependents..'........ 15,000-30,000 2/ 

Total..... 30,000-45,000' 


l/ This figure is, more precisely, .the number with sufficient employment 
tc£be counted on an ahnual"'basis’.' In this sense^, it is ;ih effect an 
estimate of the number of jobs ’rather than the number ; of persons. 
coVered for workmen's’ compensation. Since ^workt'accident insurance 
protection would have no eligibility conditions other than employ¬ 
ment, and no. earning^ limits, there may be’ many '-more persons than 
jobs covered in the'’course. of a year, perhaps as many as 20,000 
pdrsonsj . t . _ t * . 

2/ Assumes. 1-2 eligible’ dependents per r qualifying employee. Fragmentary 
data,suggest that .the factor .is probably closer ^bo 1 than 2, but a 
wide rah’ge is used until more reliable -information become^, available. 












- 103 


«• 


Expected Costs (Expenditures) for Medical Benefits 

For this coverage in the Port-au-Prince area, the expected annual 
costs (expenditures) for the medical benefits (at 1949-50 dollar levels) 
are as follows— 


For workmen's compensation ,,...... , 

For sickness and maternity insurance 2/ 

For employees only. 

For dependents only. 

Total. 


ooooooooooo 


OOOOOO 000*000000«0000 


.OOOOOOOOOOOOOOOOOOOO 


W 000000*00 


$44,000 - $88,000 1/ 
95,000 3/ 

95,000 - 190,000 4/ 

190,000 - 285,000 


1 / Assumes medical benefits for workmens compensation will cost 0.5- 
loO percent of total annual earnings covered by this insurance system, 
based on limited data available from various experiences. (See 
chapter VI.) 

2/ Estimated on the assumption that coverage includes only employees with 
earnings up to $500 per month and that only earnings up to $300 per 
month are subject to the insurance contribution rates. This is an 
intermediate assumption. According to the Social Insurance Law of 
October 1949, compulsory insurance would apply to those who earn not 
more than $300 per month, and earnings up to this amount would be 
subject to contributions. On this specification, average annual 
covered earnings would be only about 90 percent of the estimate used 
above. If, on the other hand, there were no income limit on coverage, 
and contributions were payable on earnings up to $500 per month, 
average covered earnings would be about 128 percent of the estimate 
used above. (See chapter V.) If the lower specifications are finally 
adopted, medical benefits might have to be reduced; if the higher, 
they could be expanded as personnel and facilities become available. 

3/ Assumes cost for employees (only) will equal about 1.5 percent of 
covered annual earnings, based on analysis and estimates by types of 
service. The amount shown here excludes a contingent item (5 percent) 
reserved in the insurance fund. (See chapter V.) 

4/ Assumes same per capita cost (for medical benefits) as for employees, 
and allows for 1-2 dependents per employee. 


The magnitude of these figures may be seen by a comparison with the total 
annual budget of the General Hospital in Port-au-Prince—which was about 
$250,000 for the year to which the above estimates apply. 

By comparison, workmen's compensation medical benefits (hospital, 
physicians, etc.) would involve an amount of service equal in cost to 
about 20-40 percent of the total cost of services furnished by the 
General Hospital. 









- 104 - 


Similarly, sickness and maternity insurance in Port-au-Prince 
would involve medical benefits (in-patient and out-patient) involving 
about $100,000-$300,000 a year, equal to about 40-120 percent of the 
total cost of services provided in the last year by the General Hospital, 
the range depending on the inclusion or exclusion of the dependents of 
insured employees. 

Both insurances together would involve costs equivalent to about 
55-150 percent of the total cost of operating the General Hospital 
without insurance. 

The wide range in these estimates reflects the uncertainties in 
the amount of services that will have to be provided as insurance 
benefits, and in their costs, and—more importantly—whether the coverage 
of the sickness and maternity insurance is restricted to employees or 
extends to their dependents as well. 

Estimates by Services 


Workmen’s Compensation 

There are no data available at this time on which to base a 
reliable subdivision of the workmen’s compensation cost estimates by type 
of service to be furnished. It may be assumed that one-third to one-half 
of the money will have to be used for in-patient services, and the 
remainder for clinic, office and home care. Most of it will presumably 
be spent for surgical care. These assumptions suggest the need for 
about 20-30 beds and attendant in-patient services if experience will 
show that the lower total cost ($44,000 a year) is sufficient; and the 
need for about U>-60 beds and attendant services if the higher total cost 
($88,000 a year) has to be incurred. 

Under the lower total-cost assumptions, there would be about 
$22,000-$30,000 a year for clinic, office and home care—requiring the 
time of about 4.5-6 full-time physicians (at the annual salary rate of 
$3,000), facilities, supplies, prescribed medicines, appliances, 
laboratory services, etc. (The proportionate distributions used here 
are the same as in chapter V). 

If the amount of care needed is higher (total cost of $88,000 a 
year), there would be needed—-in addition to the in-patient services— 
about 9-12 full-time physicians, plus facilities, supplies, laboratory 
services, etc. required for their clinics and offices, and the 
prescribed medicines and appliances. 

Sickness and Maternity Insurance 

The breakdown of the annual cost estimates for medical benefits 
under sickness and maternity insurance, developed in chapter V, may be 








- 105 - 


summarized as follows— 


In-patient services Beds 1/ 

For employees only... 45°5 

For dependents only.. 45°5-91oO 

For both........... 91.0-136.5 


Clinic and home care 

For employees only., 
For dependents only, 


For both 


OOOOOOOOOOO 


Full-time physicians 

~Z - - 

6-12 

12-18 



Dentistry 

For employees only., 
For dependents only, 


For both 


OOOOOOOOOOO 


Full-time dentists 2/ 
2 

2-4 

4-6 


1/ As before, "beds’* refers to bed and board, attending services, 
etc. 

2/ Physicians or dentists plus attendant services, supplies, facilities, 
etc o 


In addition, the cost estimates include provision of $3?000- 
$9,000 a year for nursing services, especially "visiting" or "hourly’ 1 
nursing (this is additional to nursing services in the hospital and 
clinic); and $7,500—$22,500 a year for prescribed drugs and medicines. 

Summary of Facilities and Personnel 
The tentative estimates may be summarized as follows— 


Workmen's Sickness and 

.. maternity 

compensation . J ^ , 

insurance 1/ 

Both 

insurances 

Beds (and attendant services) 

25-50 

46-137 

71-187 

Physicians (full-time). 


3-8 

5-11 

For in-patient services..... 

2-3 

For clinic and home services 

6 

6-18 

12-24 

F or b 0 th 0000000000000..000 

8-9 

9-26 

17-35 

Dentists (full-time)oo..o.oooo 

1-2 

2=6 

3-8 

Nurses (hospital, clinic, home) 

18-21 

21=60 

39-81 


1/ The lower figures in this column apply to a coverage of employees; 
the higher figures apply to both employees and their dependents. 




















- 106 - 


Supplemented by the personnel that would be needed for supporting 
services (laboratory personnel, pharmacists, administrative personnel, 
aids, etco) these figures may serve to give an approximate picture of 
the facility and personnel needs* Almost needless to say, these are 
only very crude estimates. They are subject to the many uncertainties 
which surround the assumptions that were used. With changes in the 
proportionate allocation of funds among the services, these estimates 
would have to be changed correspondingly. 

The staffing of hospital and clinic used here is lower (per bed 
or per patient) than is customary in the United States of America and 
in some other countries, but it is at much higher ratios than are now 
found in the public hospitals of Haiti. 

Owing to the approximate nature of these estimates, no attempt 
is made to refine or adjust them by reductions for services already 
being furnished to the persons who would become insured. It is estimated 
that such reduction would be relatively small—probably not as much as 
10 percent. 


Estimates of Capital Costs 

From the summary figures, however crude, it is possible to 
estimate the capital investment which may be involved if the facilities 
needed for these services have to be constructed. 

On the basis of available information, it appears that the needed 
facilities would cost about $4,000-$5,000 per bed to build and to furnish 
with the necessary durable equipment. These figures should not be 
misunderstood. As is common when referring to hospital costs, the basic 
cost is here expressed in terms of “dollars per bed*; but it includes 
not only the wards and private or serai-private rooms, but also the 
supporting facilities—operating and dressing rooms, service facilities, 
laboratories, out-patient clinics, etc. And a basic cost figure of this 
kind is for permanent construction, efficiently performed. 

If the construction is for the lower estimates of the needed 
facilities (i.e., 25-50 beds for workmen’s compensation only), the 
higher dollars-per-bed figure ($5,000) would apply; if for the largest 
estimate (i.e., about 187 beds) the lower dollars-per-bed figure ($4,000) 
would apply. If the facilities involved here were merely part of a 
much larger permanent hospital unit (e.g., a 500-600 bed general hospital), 
the cost estimate might be placed at about $3,500 per bed. 

The unit cost figures (doliars-per-bed) may be applied to the 
various estimates of facilities needed to provide the medical benefits. 

If, at the one extreme, the program is limited to workmen’s compensation, 




- 107 - 


the needed facilities (25-50 beds, plus clinics) may involve about 
$125,000-$250,000 for comprehensive and permanent construction and 
equipmento If, at the other extreme, the program includes both workmen’s 
compensation and sickness-maternity insurance, with the latter covering 
dependents as well as employees, the needed facilities (70-190 beds, plus 
clinics) may involve about $315,000-^760,000 for such construction and 
equipmento Further studies could narrow these ranges;l/ and they would 
be automatically narrowed by policy decisions on insurance coverage 0 

It should be emphasized that these figures apply only to the 
limited insurance coverages that were specified at the outseto If the 
coverage is different, or if allowance is to be made for expansion of 
coverage beyond that of the initial administrative undertaking, the 
figures should be adjusted. 

It should also be emphasized that these figures for total capital 
costs may be somewhat unduly and unnecessarily high because of the way 
in which they were calculated„ They derive from the estimates of beds 
and personnel needed to meet IDASH obligations to provide medical benefits„ 
And those estimates, as pointed out earlier, were derived from cost 
estimates which were deliberately generous in order not to under- estimate 
the total cost of insurance benefits or the needed contribution rate. 

The figures for permanent capital construction and equipment of hospital 
and clinic facilities could therefore be safely deflated by (say) 25 
percent, if necessary 0 Or, if used as they are, they could be considered 
sufficient to provide the facilities needed for the initial limited 
program and still leave a substantial margin for uncertainty in the 
estimates and for about 25 percent expansion of coverage„ 

These construction costs apply to fully equipped and permanent 
facilities. Consider an alternative 0 Suppose IBASH were to start with 
only a limited program in the Port-au-Prince area, while a new general 
hospital were being planned or constructed to meet the needs of IDASH 
as well as of the general public program<> IDASH beneficiaries would need 
only temporary facilities in the interim—better facilities than are now 
available but not necessarily as good or as expensive to construct and 
equip as a permanent hospital and clinic structure„ To meet such a 
temporary need, adequate for up to 5-10 years 5 service, a 50-bed unit 
with in-patient and clinic facilities and equipment would cost about 


1/ For example, the range for sickness and maternity insurance would 
be very much narrowed if a more precise estimate could be made of 
dependents per employee in place of the broad range used here<> 








- 108 - 


$75,000-$100,000 (about $1,500-$2,000 per bed).£/ If such a unit could 
be prepared by alteration of an existing building, the cost would be less. 

Depending on whether the capital funds are obtained as a contribu¬ 
tion from the Government, or have to be derived from IDASH's own reserves 
or from loans, the charge on the operating costs will be at one rate or 
another. If the capital cost has to be repaid, interest payments and 
amortization of principal should be a concurrent charge on the operating 
budget. The current cost estimates used earlier included some margins 
against this contingency. 


2/ This estimate is based on the cost of constructing and equipping 
the Hospital Isaie Jeanty. The basic cost was about $700 per bed, 
including planning, supervision, construction and equipment. It 
is increased here by 20 percent to allow for the higher cost of 
beds mainly in semi-private units. This adjusted figure ($840 per bed) 
is increased by 40 percent to allow for out-patient facilities 
($1,176 per bed), and this in turn by 25 percent to take account 
of the higher unit cost of a 50-bed unit ($1,470 per bed). To 
allow for higher current cost of construction and equipment, and 
for contingent items, the adjusted cost is increased by another 
20 percent ($1,760 per bed). 



- 109 - 


CHAPTER VIII 

The Provision of the Medical Benefits 


Introductory Note 

It is fundamental for both sickness and maternity insurance and 
for work accident insurance.;that there shall be reasonably adequate 
resources (physicians, hospital beds, clinic facilities, etc 0 ) for the 
provision of the medical benefits to the insured persons 0 But having 
the resources, though obviously the first essential, is not enough. 

There must also be effective -arrangements between the insurance system 
and these resources to assure ready availability of the services as 
needed by the insured persons. These arrangements must include paying 
. for the services through methods that are administratively efficient 
both to' the insurance system and to the facilities and personnel that 
furnish the services 0 Moreover, the payments must be within the means 
of the insurance system, and yet sufficient to support the services and 
to encourage high quality of care 0 

The survey of present resources for medical and hospital care 
shows that Haiti is deplorably weak in these necessities 0 The total 
resources are insufficient in amount, inadequate in quality of service, 
and too unevenly distributed throughout the country to meet the needs 
of the proposed insurance systems. In Port-au-Prince, where there is 
a heavy concentration of the available resources, the hospital beds are 
already being used at the maximum rate for efficient utilization—and 
even above that level. In the provincial towns, the utilization of the 
hospitals is more uneven, though in general it is substantially maximalo 
Physicians, on the contrary, are by no means fully utilized. Though 
need for medical services is vast throughout Haiti, effective demand for 
the services of physicians is limited—even by comparison with the low 
ratio of physicians to population.. 

There are many reasons for failure to use to their full capacity 
the meager medical resources that are available. Lack of education on 
the use of these resources is undoubtedly one of the most important 
reasons. All evidence indicates, however, that lack of ability to pay 
for needed care is at least equally important. 

In addition, professional factionalisms and so-called "political" 
factors gravely interfere with the effective use of Haiti’s limited 
hospital, clinic and personnel resources for the full benefit of the 
nation’s health. Coupled with inadequate financial support of medical 
practitioners and facilities, these interferences have encouraged some 
physicians and* other trained personnel—who should be here serving the 
Haitian population—to settle and practice in other countries; and many 




- 110 - 


who are in Haiti have temporarily or permanently left their professions 
to engage in other occupations<> 

Public and Private Medical Resources 


It may be useful at this point to review and summarize the 
resources for personal medical services» They may be considered as 
being in two parts. There is first* and in the main, the system of 
public hospitals, with salaried staffs and with clinics or out-patient 
services in and related to them 0 This system is an integral part of 
the Department of Public Health and is administered by its officers» 

Second, there is a system—if it can be called that—of private 
practitioners« 

The public system consists basically of: (a) The hospitals in 
Port-au-Prince—the General Hospital with somewhat more than 500 beds, 
the maternity hospital (Hospital Isaie Jeanty) with about 100 beds, 
and the tuberculosis sanatorium with about 100 bedsj and (b) 10 general 
public hospitals located in the main provincial towns, with from 40 to 
265 beds eacho In the aggregate, the public hospitals have 1,676 beds 
throughout the country. In addition, there are about 140 dispensaries, 
operating as out-patient clinics of the hospitals and as rural dis¬ 
pensaries o They are of very uneven quality and value«, Each hospital 
has a salaried staff of physicians, nurses, nursing-aids, etc» The 
public hospitals and clinics employ in the aggregate about 125 physi¬ 
cians, about 50 percent or more of the total actually in Haiti and 
engaged in the practice of medicine 0 

The private system of medical services consists mainly of about 
117 medical and about 66 dental practitioners working in and from their 
own offices or * clinics „ n Of the 117 physicians who are counted as 
private medical practitioners, because they are not in the public employ, 
it is reported that only about 50-75 are actually in Haiti and available 
for general or special service to the population.. In addition, however, 
practically all of the physicians who hold salaried staff appointments 
in the public hospitals*must also be counted as private practitioners 
because nearly all of them supplement their public salary by engaging in 
private practice to such extent as they cane 

Private resources include in addition about 77 beds in two small 
private hospitals and in about half a dozen offices or "clinics” 
maintained by private practitioners» 

Obviously, the existing public hospital and clinic system is Haiti’s 
main resource for personal medical services« It includes nearly all of 
the hospitals and practically all of the hospital beds, a large proportion 
of all the physicians, a portion of the dentists, and practically all of 



- Ill - 


the trained nurses and nursing-aids. It is carrying most of the load in 
the provision of personal medical services« Though operating substantially 
at full capacity, it is grossly inadequate to meet the needs of the 
populationo It is inadequate not only quantitatively but also quali¬ 
tatively; on this, everybody in Haiti is agreed, including the responsible 
administrative officers, the practitioners (salaried and private) and the 
public o 


If the public system is to be made adequate, it must have large 
expansion, rebuilding, re-equipment, improvement in administration and 
in quality of care, To achieve these objectives, there must be greatly 
enlarged financial resources to support the system, both for capital 
construction and equipment and for annual operating costs, There must 
also be many fundamental reorganizations of administration and practice— 
to give greater security of tenure to the staff and to assure advancement 
on the basis of merit, to strengthen a sense of discipline and 
responsibility in the services, and to advance the quality of care. 

Adequacy of the Resources to Provide Insurance Benefits 

Potentially, the social insurance systems could look to the existing 
resources, especially to the public hospital and medical system, to 
provide the services which would be promised as medical benefits to the 
insured persons. But this would be a satisfactory arrangement for 
meeting the insurance obligations only if the services to the insured 
persons will actually be available to them in suitable quantity and 
quality. Such a result could be achieved only if the present resources 
were greatly enlarged; or, in the alternative, if enough of the present 
resources were reserved for the insurance beneficiaries, or if these 
persons were given some kind of practical and acceptable assured priority 
of access to the existing resources; and only if the quality of the 
services were improved so that the insured persons would be satisfied 
that they were getting value received for the insurance premiums paid 
by them (and by their employers). 

The existing private resources are even more insufficient in 
total and they would not of themselves be able, place by place, to meet 
the needs of the potential insurance beneficiaries—if the social 
insurance system has substantial coverage in the Port-au-Prince area or 
over the nation generally. The number of private practitioners, now 
small, could of course be rapidly expanded by drawing from the public 
system; but there are substantially no private facilities for in-patient 
care or for the organized (clinic) care of ambulatory patients. If the 
insurance system were to consider relying on the private resources, 
facilities would have to be developed. 

The total resources for personal medical services, public and 
private combined, are insufficient to meet the obligations of nation-wide 



- 112 - 


coverage under the social insurance systems. In Port-au-Prince, however, 
because of the disproportionate concentration of medical resources in 
this area, there may be nearly enough quantitatively—if not quite 
enough—to meet the obligations of the insurance system. With appropriate 
enlargements of hospital and clinic facilities, and with necessary improve¬ 
ments in organization and in adequacy of service, there could be sufficient 
resources at least for an insurance system which started with limited 
coverage, 

These conclusions concerning the potential capacities of the 
public and private medical resources to meet the obligations of the 
insurance system are independent of the nature of the arrangements through 
which the insurance system undertakes to meet its medical benefit 
obligations, 

Alternative Patterns for Providing the Medical Benefits 

Ip deciding how to provide the medical benefits, IEASH is 
confronted by four possible alternatives; 

(a) As specified in the social insurance law of October 1949, 
it could undertake to provide services to the maximum 
extent possible in and through its own medical resources 
(hospitals, clinics, etc,). This would mean that IDASH 
would have to construct facilities, staff and manage themj 

(b) IDASH could rely on public hospitals and clinics operated 
by the Department of Public Health, arranging for that 
Department to fumish the services to the insured persons 
and agreeing to reimburse it for services rendered to 
insurance beneficiaries, 

(c) IDASH could rely on private practitioners to furnish the 
medical services, utilizing hospitals, clinics and private 
offices, built and owned by those practitioners, or through 
hospitals and clinics built for them by IDASH, or built by 
them with loans from IDASH or from other sources (these 
alternatives are suggested by some representatives of private 
practitioners); 

(d) IDASH could utilize a mixed system—-developing its own 
facilities, utilizing the resources of the public system 

of the Department of Public Health, and supplementing these 
by the services of private practitioners who are under 
contractual agreements with the insurance system. 



- 113 - 


IDASH is confronted with these alternatives, and it must make a 
choice o Obviously, it should make its choice with regard not only for 
its obligations to meet the needs of the insurance system but also with 
regard for its potential role in contributing to the larger health needs 
and programs of Haiti as a whole® 

An IDASH System 

The first alternative, operating through IBASH’s own facilities 
and staff, has the obvious advantage that the insurance program could 
build and staff its facilities to meet its obligations® It could provide 
services that are adequate in quantity and in quality® 

This method also has obvious disadvantages® It calls for 
substantial capital funds, and it would be a large and complicated 
undertaking® This would be an especially serious obligation in the 
first years when IDASH would be going through the critical period of 
organizing, recruiting and training staff, developing administrative 
procedures, engaging in necessary public educational activities, etc® 

It might also be more expensive than some other alternative, at least 
for the first years® Also, the selection of this alternative and the 
development of an IDASH system of medical facilities and personnel would 
lay the basis for a dual system of medical resources in Haiti—the 
general public system of the Department of Public Health and the IDASH 
system® This could result in competitive and rival organizations—in a 
country which does not now have even minimum adequate medical resources® 
This objectionable feature of the choice might be more serious under 
present conditions than at a later time when total resources are larger® 

On balance, it appears that this first alternative should not be 
IDASH*s first choice for the initial period® If this pattern is neverthe¬ 
less chosen, it should be implemented only very slowly, step-by-step, 
and only as necessary to meet the obligations of a coverage which is 
similarly expanded in successive steps or stages® 

Use of the Public Health System 

The second alternative, operating by relying upon the Department 
of Public Health to furnish the medical benefits, it obviously the 
simplest and easiest approach in principle . 

The adoption of this pattern would relieve IDASH of the 
complexities and burdens involved in planning, organizing, building, 
staffing and managing a hospital and medical system® Such relief for 
IDASH would be especially important in its first years, when it is 
tackling the difficult problems involved in organizing an insurance 





- 114 - 


system and getting into operation Moreover, by undertaking to purchase 
the medical services needed to meet medical benefit obligations, and by 
paying for the services, IDASH could pri>vide valuable financial support 
to the public system. Such support could be adequate in amount and 
assured in continuity for the support of higher quality care than is 
now furnished by the public system. IDASH operations and finances could 
therefore bring new, strength and new hope and promise to the public 
system, rather than competition and rivalry and the danger of contribu¬ 
ting to the deterioration* of that system. 

*4 

However, provision of the insurance medical benefits through the 
Department of.Public ( Health is a practical choice only if IDASH can be 
assured that the Department will actually be able to provide the services 
in adequate quantity and quality and under Cbnditiori^ that make the 
services acceptable,and .satisfactory to the insured persons. If it 
cannot have such assurances, the choice of this alternative would be 
a serious mistake and could have disastrous results for the insurance 
program. 

Operation Through Private Practitioners 

1. • 

If IDASH chooses the third alternative, it could rely upon fcll 
the practitioners, who^are now engaged in the private practice of 
medicine (whether or not also on the salaried staffs of the public 
system).. But it would have to develop service contracts with them, 
agreements as to methods and rates of payment for services rendered'to 
insured persons*, arrangements for checks and reviews on services, costs, 
etc. IDASH would also have to effect arrangements for these practi¬ 
tioners .to have the privilege of serving insured persons as in-patients 
in the public hospitals and clinics, or it would have to encourage or 
aid these physicians to build and staff hospitals and clinics, or it 
would have to provide them with such facilities through insurance funds. 

This pattern, in one or another of its variants, is strongly 
urged by some representatives of the medical societies and by some 
practitioners who are wholly or mainly engaged in private practice.1/ 

This pattern would mean, in the long run and for a more or less fully 
developed and extended social insurance system, the provision of insurance 
benefits by all the physicians of Haiti who wish to participate in it, 
wherever located. This pattern would also mean the development of a 
system of private hospitals and clinics built through capital .provided 
by IDASH or others, and subsequently supported by continuing maintenance 
payments from IDASH. 


1/ See!; for example', the report by Dr. Auguste DENIZE^in the Bulletin 
de 1*Association Medicale Haitienne, January 1951, pages 48-53<» 




- 115 - 


As noted earlier, this pattern would probably result in drawing 
staff away from the public system into the insurance-supported private 
practice. To the extent that IDASH, through its insurance funds, 
could pay at higher rates than the public system, the IDASH system would 
draw staff away from the public system selectively, with potentially 
serious adverse consequences for the public system and for its 
opportunities to expand and improve services for the population outside 
the insurance system. 

Use of a Mixed System 


If IDASH chooses the fourth alternative, obviously it could have 
the advantages of utilizing all the existing aibd all the future medical 
resources of Haiti, This is obviously what is needed in principle ; and 
it is strongly urged by some representatives of medical societies and of 
private practitioners. But it is obvious that, to the extent that the 
pattern uses multiple resources through diverse arrangements, it also 
involves IDASH in many complexities of contract, organization and 
administrations. Also, as for some of the other alternatives, there is 
a serious question whether the cost of such a multiple system of medical 
benefits would be the lowest for which IDASH could meet its insurance 
obligations at a reasonably satisfactory level. 

Outlook for Enlarged and Improved Resources 

This problem which confronts IDASH obviously would not exist if 
the public hospitals were adequate in size and quality of service. It 
is therefore important to take note of plans under consideration for 
the construction of new facilities and the modernization of parts of the 
old. 

There is widespread agreement about the inadequacy of present 
hospital resources in Port-au-Prince for both in-patient and out-patient 
services. The same is true for the hospitals elsewhere, though in some 
places the deficiencies of equipment, supplies and staff are apparently 
more serious than the deficiencies of over-all size. 

The acute situation in the capital area has been receiving the 
attention of the Government, especially because the General Hospital 
serves not only cases arising in this area but also referred cases from 
other parts of the country. Plans for new hospital facilities are 
receiving close study (March 1951)« 

With respect to the social insurance programs, there can be no 
doubt that the construction of new hospital facilities in Port-au-Prince 
Yfould invite IDASH to gear its plans to this project. If the new 
facilities are built according to the plan now being considered, they 





- 116 - 


could become available about mid-1953 or soon thereafter* IDASH should 
certainly give serious consideration to the opportunity presented by this 
prospect for improved facilities and services <> If the project is not 
-undertaken, or is long delayed, IDASH has to consider alternative plans* 

The reasons were given earlier why IDASH should cons er making 
a beginning with social insurance limited at the outset to Port au-Prince 
and its environs, and with limited insurance coverage* If the hospital 
and medical resources are still very limited when IDASH is ready to begin, 
and the outlook is that they will continue to be inadequate, IDASH would 
have an additional reason for starting only with work-accident insurance 
until it has gained administrative experience and until enlarged 
facilities are available* If it seems unlikely that the needed enlarge¬ 
ment and improvement of facilities are to be realized through the public 
hospital system, obviously they would have to be brought about by IDASH 
itself—to the extent necessary to meet the insurance obligations* 

If IDASH decides to proceed with a limited program in the interim 
(e*g., with work-accident insurance only), there are indications that 
the Department of Public Health can prepare the necessary hospital and 
clinic facilities to provide the medical benefits* Such a limited 
insurance program would need only relatively small facilities—about 
25+-60 beds, and out-patient clinics staffed by about 6 physicians, or 
somewhat less than these figures indicate (see 8hapter VII)* A hospital 
and clinic of this size probably would not be a highly economical unit, 
if self-contained* Therefore, it would be unwise for IDASH to urdertake 
to construct, equip, staff and manage it, if this task can be avoided. 

This pattern of reasoning invites IDASH to arrange for medical benefits 
for an initial, 1 mited program through the Department of Public Health— 
if it can do this with adequate guarantees* 

If the benefits for insurance in the Port-au-Prince area are to 
be provided at the General Hospital, the services must bessubstantial¬ 
ly improved* The financial analyses have shown that IDASH could pay 
adequately for services of much better quality than are furnished there 
now. Its agreement to do so can provide the necessary financial 
assurances so that the General Hospital can afford to effect the improve¬ 
ments that are needed for so many beds and such clinic facilities as 
would be necessary to provide the insurance benefits. 

The availability of IDASH funds to pay for relatively high-grade 
services for the insured persons—sufficient funds to pay for facilities, 
equipment and supplies and to pay at adequate rates for competent 
selected staff, should encourage improvement of all services and not 
merely of those provided to insured persons * This should also encourage 
physicians generally about the future of medical practice in Haiti and 
should accelerate the needed improvements in medical education. And it 
should have similar beneficial effects for dentistry and nursing. 


- 117 - 


New financial support from IDASH will not, of itself, solve all 
the problems that are presented by the General Hospital in Port-au-Prince 
and the general hospitals elsewhere. As remarked earlier, the present 
public hospital system is severely criticized by many people—and with 
good reason. To the extent that the criticisms are Justified, IDASH 
should expect to have firm assurances that objectionable administrative 
practices or functional conditions would not be permitted to persist to 
the point of interfering with the provision of adequate services for 
the insured persons 0 

If IDASH finds that it can effect the indicated contracts with 
the Department of Public Health, with good assurance that the needed 
services will be available—in adequate quantity and quality, it could 
proceed with its plans for a first experiment in organizing and 
administering social insurance, And it could do so with much less 
difficulty than if it had to provide for the medical benefits by any of 
the alternative methods 0 If this pattern is followed and is found to 
work well, the arrangements could be extended for broader insurance 
coverage; and the experience in Port-au-Prince could provide the pattern 
for insurance operations extended to other areas. 

If such an arrangement cannot be effected, or if such a pattern 
does not work effectively (even for limited insurance coverage in 
Port-au-Prince), IDASH would have to consider another choice among the 
alternative methods of providing medical benefits. It would have to 
give equally careful consideration to constructing and operating its 
own facilities, and to contract arrangements with private practitioners 
for services rendered on fee-for-service, capitation or salary (full-time 
or part-time) basis. 


- 118 


CHAPTER IX 

• ‘ Administration of Social Insurance 


Introductory Note 

• • •: > v. -* . ' 

The administration of.social insurance has’to meet the require¬ 
ments and obligations which apply to all public agencies* In addition, 
it has to meet the special and more exacting requirements -which arise 
from its insurance nature. 

•'* In the ca'se of a*, general . public service, the relationship 
between particular taxes and services is usually remote and ambiguous. 
In the case of social insurance, 4 the^relation between insurance contri¬ 
butions and benefits is both direct and clear. - • 

- +» • • v •• • * • *•••, / 1 . * »' b 

' '^Large numbers of employers' and employees make periodic earmarked 
contributions to a social insurance’ system. In return, they expect 
insurance benefits which are'equal 'in value' to the contributions paid 
and which are furnished with efficiency and’ economy. 

Since a social insurance system operates through special and 
independent financing, it> has'to protect its solvency against short¬ 
term or long-term’fluctuations in income'and outgo through maintenance 
of reserves whose safety and availability-must be assured. And since 
the insurance system has to have long-term continuity, to be successful 
it-must win and keep public confidence in its competence, efficiency 
and ‘integrity. 1 * ■ , f ’* ' 

To meet these special requirements, social insurance administra¬ 
tion has devised and uses special methods (a) to inform covered employ¬ 
ers and employees about the insurance system and how to participate in 
it, (b) to collect and manage contributions, (c) to arrange for the 
payment of cash benefits to insured persons and to provide medical 
benefits to them and their eligible dependents, and (d) to give a 
satisfactory accounting to the contributors. 

Over the long history of voluntary and compulsory social 
insurance, through centuries in Europe and decades in other parts of 
the world, a special kind of administrative institution has evolved. 

It is an autonomous or quasi-autonomous institution, adapted to the 
administration of this public service. It has gained widespread 
acceptance, though the details of its form differ among the countries 
that have adopted social insurance. 

The Haitian Social Insurance Law of October 1949 shows 
familiarity with this background. It provides for administration of 
the social insurance programs through IDASH, a more or less autonomous 





- 119 - 


institution. Though substantially self-contained, as indicated in the 
sumnary of the Law in chapter I, IDASH would have certain specified 
relationships to the President and to certain of his Ministers. For 
example, all nine members of the Conseil d*Administration would be 
appointed by the President; and three would be representatives of the 
Government, chosen by the President from the Departments of Labor, 

Public Health and Finances (the other six from panels of names sub¬ 
mitted by employers and labor)® 

Criticism of the IDASH Organization 

When IDASH and its Conseil d 9 Administration were activated in 
July 1950, this substantially autonomous insurance institution came 
into being® Shortly thereafter, various criticisms were raised. Some 
of the complaints were concerned with substantive specifications in the 
Law, and others with questions of timing and public preparation for 
inaugurating the program® But still others were focused on the autono¬ 
mous nature of IDASH itself, especially on its substantial apartness 
from the general Government of Haiti. A serious question was raised 
whether it is practical or desirable to have social insurance in Haiti 
administered by an autonomous administrative body. It was proposed 
that, instead, social insurance should be administered as are other 
public functions, with the administrative responsibilities lodged in 
a regular department of the Government (the Department of Labor)® All 
of these questions were left in suspense when on September 28, 1950 
the interim Government under the Junte decreed the indefinite suspen¬ 
sion of the Law® 

For the reasons which lie behind the evolution of special 
administrative techniques for social insurance, it would appear to be 
unwise and unsound for social insurance administration in Haiti to be 
incorporated in the usual way within a regular department. It is 
apparently equally objectionable to have a wholly autonomous institution. 
Something between the two appears to be desirable—preserving the advan¬ 
tages that many countries have found in the autonomous institution, and 
yet assuring close policy coordination with the Government as a whole 
and with those of its departments that would be specially concerned 
with particular aspects of social insurance operations. 

Revised Organization of IDASH 

Two solutions to this problem may be suggested for considera¬ 


tion: 






- 120 - 


Plan A -would keep the basic framework of the autonomous 
institution which is no?/ in the law, but amend it to 
ensure, coordination with the general Government! 

Plan B would make IDASH an integral part of a regular 
department of the Government (the Department of Labor), 
but preserve certain characteristics of the autonomous 
administrative institution which are especially- useful 
and important for social insurance. 

In either case, the result would be a coordinated semi- or quasi- 
autonomous institution. 

Outline of Plan A 

The specifications of the Law of October 1949 might be amended 
so that IDASH would still be an autonomous institution in the sense of 
being a separate legal entity, and of having separate property and 
financing. But IDASH would be coordinated with the general Government, 
as through the following specifications— 

a) The appointment of the three Government members of 
the Conseil would be made by the President on the 
recommendation of the Ministers concerned (Labor, 

Public Health and Finances); 

b) The appointment of the other members of the Conseil 
(representing employers and labor) would be made by 
the President on recommendation of the Minister of 
Labor from panels of names submitted by the respect¬ 
ive groups; 

c) The member of the Conseil representing the Department 
of Labor would be the Chairman, ex officio ; and the 
Conseil would elect the Vice-Chairman and Secretary 
from among its other members. 

d) The President would appoint the Director from nomina¬ 
tions submitted to him by the Conseil through the 
Minister of Labor, and would have authority to remove 
the Director on recommendation of the Conseil through 
the Minister of Labor, or on his own motion; 

e) The Conseil would have responsibility for the general 
policies of the program and of administration, and 
for general supervision of the Director and his 
operations; 











- 121 - 


f) The Director would appoint, promote and dismiss 
subordinate personnel, in accordance with policies, 
standards and procedures established by him with 
the approval of the Conseil as to selection on a 
merit basis, tenure of appointment, and promotion 
and dismissal policy; 

g) The general policies of IDASH would not be formally 
adopted or effectuated, and general decisions (within 
the latitudes authorized in the Law) concerning cover¬ 
age, contributions and benefits would not come into 
operation, until approved by the Minister of Labor— 
who would act on financial matters after consultation 
with the Minister of Finances, and on health and 
related matters after consultation with the Minister 
of Public Health; 

h) The Conseil and the Director would be required to 
make annual reports to the President through the 
Minister of Labor, giving full accounts of operations 
and problems, and making recommendations for amend¬ 
ment and improvement of the program, which the Minister 
should transmit to the President with comments thereon 0 

i) The financial operations of IDASH would be audited 
annually by officers designated by the Minister of 
Finances; 

j) Various health and medical benefit programs of IDASH 
would, to the maximum extent practical, be expected 
to be either integrated or coordinated with the 
program operations of the Department of Public Health; 
and, by mutual agreement between the Director of IDASH 
and the Director General of Public Health (the respective 
Ministers concurring), might be operated for IDASH by the 
Department of Public Health on a reimbursable basis» 

Outline of Plan B 

In the alternative, the specifications now in the Law night be 
amended so that IDASH would be part of a regular department of the 
Government (i 0 e„, the Department of Labor), but would have its own 
legal identity, conduct its detailed operations as to contributions 
and benefits in its own name, and have separate property and financing. 
The Law would need amendment to achieve the following— 





- 122 - 


a) The administration of IDASH would be the responsi¬ 
bility of a Director, assisted by an Advisory Council, 
all under the general direction and supervision of the 
Minister of Labor? 

b) The President would appoint the Director on advice 
of the Minister of Labor, after the latter has 
consulted with the Advisory Council, and would have 
authority to remove the Director on recommendation 
of the Advisory Council through the Minister, or on 
his own motion? 

c) The nine members of the Advisory Council would be 
appointed by the Presidents the three Government 
members on the recommendations of the Ministers of 
Labor, Public Health, and Finances, respectively? 
the other six members (three from employers and 
three from labor) on recommendation of the Minister 
of Labor from panels f names submitted by the 
respective grou s, the member representing the 
Department of Labor would be Chairman ( ex officio ) 
of the Advisory Counci ? and the Council would 
elect its own Vice-Cha..,rman and Secretary. 

d) The Advisory Council o Id have responsibility to 
advise the Director on all general policies of 
administration and periodical! to review his 
operations, and would have to be consulted by him 
before he adopts general policies? 

e) The Director would appoint, promote and dismiss 
subordinate personnel, in accordance with pol T c:’es, 
standards and procedures established by him after 
consultation with the Advisory Council and approval 
of the Minister of Labor as to selection on a merit 
basis, tenure of appointment, and promotion and 
dismissal policy- 

f) The general policies of IDASH, developed by the 
Director, would not be formally adopted or effectu¬ 
ated, and general decisions (within the latitudes 
authorized in the law) concerning coverage, contri¬ 
butions and benefits would not come into operation, 
until after consultation with the Advisory Council 
and approval by the Minister of Labor—who would act 
on financial matters after consultation with the 
Minister of Finances, and on health and related 
matters after consultation with the Minister of 
Public Health. 



- 123 - 


g) The Director and the Advisory Council would be re¬ 
quired to make annual reports to the President 
through the Minister of Labor, giving full accounts 
of operations, consultations and problems, and 
making recormendations for amendment and improvement 
of the program, which the Minister should transmit 
to the President with comments thereon. 

h) The financial operations of IDASH would be audited 
annually by officers designated by the Minister of 
Finances| 

i) Various health and medical benefit programs of IDASH 
would, to the maximum extent practical, be expected 

to be either integrated or coordinated with the program 
operations of the Department of Public Health; and, by 
mutual agreement between the Director of IDASH and the 
Director General of Public Health (the respective 
Ministers concurring), might be operated for IDASH by 
the Department of Public Health on a reimbursable 
basis. 


Administrative Organization of IDASH 

Haiti cannot merely borrow an administrative pattern from some 
other country which has social insurance programs in operation. To 
have effective and efficient administration of its own programs, it 
has to devise a pattern specially suited to its own law and to its own 
circumstances and practices. 

At this time, the details of an administrative pattern cannot 
be usefully suggested. Many basic provisions of the Law of October 
1949 are subject to reconsideration, and many aspects of administration 
will be affected—one way or another-—by the decisions to be reached. 

A promising beginning has been made in achieving understanding of 
social insurance principles; but among the persons who are expert on 
Haitian circumstances and Government practices, only a few have begun 
to have some familiarity with social insurance and its administration. 
Their direct participation is essential to the formulation of a 
detailed plan, so that the results will join their knowledge of 
Haitian Government administration with the knowledge of a consultant 
who may be familiar with social insurance practice and experience in 
other countries. Detailed blueprinting of administration should wait 
until a smll but selected group of Haitians has achieved more intimate 
knowledge of social insurance administration, and is fully equipped for 
the responsibility involved in planning. A preparatory program to 
achieve this objective wil3. be outlined later. 



- 124 - 


At this point, however, it may be worth indicating the general 
functions which must be performed in social insurance administration. 
This my be helpful in guiding the selection of persons who should be 
provided opportunity to study social insurance principles and practices. 

The general functions that must be served in the administration 
of work accident insurance may be summarized as follows— 

1, General direction, budget, personnel and property 
control 

2 , Legal determinations 
3, Registration of employers 

4o Collection of premiums and auditing of payrolls 
5c Record keeping, accounting, and auditing 

6, Assessment of premiums 1/ 

7o Accident reporting and prevention 
8, Claims taking and processing 
9o Provision of medical benefits 
10e Certification and determination of degree of 
incapacity 

11„ Payment of awards 

12, Statistical, actuarial and economic research 
and control operations 

13» Informational services, and education of the 
public, employers and employees 
14* Management of current finances and investments 
15o Impartial review of complaints, appeals against 
decisions and awards, etc. 

Similarly, the functional management of sickness and maternity 
insurance involves the following— 

1, General direction, budget, personnel and property 
control 

2, Legal determinations 

3» Registration of employers, employees and dependents 
4® Issuance and management of stamp books and/or 
payroll reporting forms 
5o Sale of stamps (if this method is used) 

6 0 Collection of premiums and/or stamp books 

7, Record keeping, accounting and auditing 

8, Claims taking and processing 

9o Provision of medical benefits and operation of 
preventive programs 

10, Certification and review of incapacity 

11, Payment of cash benefits 

12, Statistical, actuarial and economic research 
and control operations 

1/ A special function required if (or when)premiums are graduated 
according to industry or establishment risk. 




- 125 - 


13° Informational services, and education of the 
public, employers, and employees 

14° Management of current finances and investments 

15e Impartial review of complaints, appeals against 
decisions and awards, etc. 

These are imposing lists 0 Nor is this surprising, since social 
insurance administration is a complex function. It is possible, how¬ 
ever, to group the functions for administrative purposes into fewer 
categories, (it would, however, go beyond the scope of this study (and 
add great bulk to the appendices) to include the detailed blueprints, 
flow-charts, rules and regulations, and forms actually used by one 
country or another. All such material can be readily obtained for 
study when the persons who are to be trained are ready for that stage.) 

A study of the functions listed above will suggest various 
combinations of special fields for which persons who are to be given 
opportunity for training should be selected. For example, a team of 
six persons might represent individuals destined to work in 

a. General administration (two) 

b. Financial aspects, claims, etc. 

c. Records, statistics, etc. 

d. Information, education, accident prevention, etc. 

e. Medical aspects of social insurance administration. 

Each of them should, of course, go through a broad training and 
preparatory program, though with attention focused on a potential field 
of specialization. Many other combinations of specialization may be 
considered, with special reference to the background, aptitudes, 
interests, etc., of the candidates available for the team. 

Training of Personnel 

and 

Development of Administrative Pattern 

In light of all the circumstances revealed by this survey, it 
appears that the training of personnel for administration and the 
development of an administrative pattern might be planned as a 
concerted program which includes the following steps— 

a) Selection of about six individuals who by ability, 
education, experience, aptitude, and interest may 
be expected toserve as the nucleus of the future 
senior administrative staff, and who have the 
language equipment for study in selected foreign 
countries. 




- 126 - 


b) Provide these individuals a preliminary full-time 
period of about three months in -which to study 
social insurance principles, history and experience.,2/ 

The purpose of this preliminary study program is to 
prepare them so that they are equipped for foreign 
study* They should not go to other countries -without 
information about social insurance in general, or 
■without advance knowledge of the programs operating in 
the countries to be visited* With such advance prepar¬ 
ation they -will be better Received and they will profit 
very much more from their visits and observations* 

c) Provide these individuals vtith opportunities to visit 
countries which operate social insurance programs* Each 
individual might have about four months in which to visit 
tv/o, three of four countries, so that he can study more 
than one pattern of administration* Each individual 
should observe at least one workmen’s compensation and 

at least one sickness (or health) insurance system. 

d) Provide for the six members of this group to have a sub¬ 
sequent period of about three months in -which to engage 
in a joint review of their studies and observations, and 
for joint planning of an administrative pattern for Haiti* 

In this period, they should design the blueprint for 
administration5 they should draft standards, operating 
flow-charts, forms, procedures, rules and regulations, 
etc* And they should begin the recruitment and training 
of subordinate personnel* This stage of the program will 
profit greatly if arrangements can be made for the group 
to work under the guidance of a consultant expert who 

has had broad experience in social insurance administra¬ 
tion, especially in workmen’s compensation and/or sickness 
(health) insurance* 

e) At the end of the preceding stage, the group should be able, 
under the general supervision and direction of the respon¬ 
sible government officers, to develop for formal adoption 

in a period of about two months a sound plan for administra¬ 
tion—-as sound as it can be in advance of actual operation* 
In this period, the evolving administrative corps should be 
completing the recruitment and training of subordinate 
personnel* 


2/ They may have associated with them in this study period others who 
are to be enployed subsequently in social insurance administration 
but who will not participate in foreign visits and studies* 



- 127 - 


f) The preceding preparatory stages should be followed 
by a period of (say) six months in which (as already 
contemplated) the Social Insurance Law is in force 
for registration of enployers 2/ and payment of 
insurance premiums 4/ —prior to provision of benefits. 

In this period, the advance administrative plans can 
be tested and perfected with respect to certain 
functions (registration, collection, accounting, etc.), 
and trials or pilot experiments can be made with respect 
to benefit claims and payments e 

g) Throughout the 18 months of stages (a)-(f), inclusive, 
the work should be proceeding to arrange for the avail¬ 
ability of the medical benefits,. At the beginning, 
there would presumably be decisions as to the general 
pattern to be followed. On the basis of those decisions, 
plans should proceed for the necessary rehabilitation and 
preparation of existing facilities (hospital, clinic, 
etc.)* or for the construction, equipment and staffing 

of new facilities required by the insurance program.j>/ 

h) Also, throughout the 18 months period , the temporary 
administrative organization should be proceeding with 
a comprehensive informational and educational program. 

This should foresee the needs for educational activi¬ 
ties with the public in general—to give them knov/ledge 
of the social insurance program, and with enployers and 
employees who are to be covered by the insurance system. 

In the first month or two, this program should be planned. 
Then, it should focus on the preparation of educational 
naterial—releases for newspapers, radio, enployers, 
schools, interested organizations and associations! 
informational leaflets! texts for speakers, to prepare 
them to address various kinds of groups! graphic posters! 
still and moving pictures, because of the importance of 
relying heavily on information and education through 
visual and auditory means! etc. The objective should be 
all possible advance preparation to inform people and to 
equip them for informed participation in the insurance 
operations. Certain of the prepared material should be 
ready for use, and should begin to be used, (say) a month 


2J If applicable to workmen’s compensation, registration of employers 
only; if applicable to sickness and maternity insurance, registra¬ 
tion of both employers and employees. 

Presumably, by enployers only. 

jj/ It is important to note the assumption here that 18 months is ample 
to assure the availability of the needed facilities. 







- 128 - 


or two before the Law is declared in force and collection 
of premiums begins„ Additional material, especially with 
reference to employee participation and the availability 
of benefits, should be ready for use in the six months 
between the date when the Law comes into force and the 
date when benefits become available. This educational 
program may be greatly aided by the availability of 
expert consultants throughout,, 

These eight stages may be recapitulated as follows— 

Stage A 

Successive Steps 

a 0 Selection of personnel 

b. Preliminary study period in Haiti 

c. Training abroad 

d. Review; and planning of administration 

e. Development and adoption of operating plan 

f e Preliminary operating period (collection 

of contributions, prior to provision of 
benefits) 

Total 
Stage B 

Simultaneous with Stage A 

g 0 Preparation for the provision of hospital, 

clinic and other medical benefits 6/ 18 

ho Preparation and performance of informational 

and educational programs 18 

This leads to an over-all 18-month schedule from the time the 
nucleus of key personnel is first selected—12 months before collection 
of insurance contributions first begins, and 18 months before benefits 
become available* 

It is possible that this is too brief and too tight a schedule,, 
If unavoidable delays are met at the early stages, the preparatory 
program should not be hurried; it should be extended to (say) 24 months 
over-all„ 


Months 


3 

4 
3 
2 


6 


18 


6/ As noted before, this assumes that the initial program would be of 
such limited scope as not to require the construction of major hos¬ 
pital and clinic facilities* If large-scale hospital and clinic 
construction will proceed^, for the purpose of serving the public 
generally and the social insurance program as well, the 18-month 
schedule outlined here should be geared to the date when that 
construction project—if not too long delayed—can assure the 
availability of the medical benefits„ 









- 129 - 


CHAPTER X 

Conclusions and Recommendations 


Introductory Note 

This study -was undertaken -when the Government of the United States 
•was asked by the Government of Haiti to furnish technical assistance in 
the development and implementation of a Social Insurance Law enacted in 
October 1949• The objectives of the study were to survey the social, and 
economic environment in which the social insurance program would have to 
operate in Haiti, and to advise whether or not, and how, it could be 
introduced and administered. 

Much of the information essential for this study was non-existent. 
Special surveys and compilations were therefore undertaken,to provide 
statistics on employment, family composition, earnings, incidence of 
incapacity and work accidents, and on resources for medical and hospital 
care. The results of these special inquiries were used in conjunction 
with population statistics resulting from the first Census of Haiti 
(August 1950) and with other information accumulated from diverse 
sources, field visits and conferences» The data and their analyses 
are recorded in some detail in this report, in order to show the grounds 
for many of the conclusions and recorrmendations summarized here, and to 
make them available for use in planning and performing further studies. 

General Conclusions 


Before turning to problems concerning how to implement the Social 
Insurance Law, it was necessary to ask whether or not it should be 
implemented. 

Many considerations lead to the conclusions that Haiti badly and 
urgently needs social insurance, and that there are no practical alter¬ 
natives for achieving the objectives which are possible through the 
method of social insurance 0 This method has important limitations for 
Haiti because the country has meager or inadequately developed resources 
for a growing population of over 3 million; it has widespread poverty 
and sickness, and massive unemployment and under-employment; it lacks 
trained personnel; and it has insufficient facilities for medical and 
hospital care. Nevertheless, despite the limitations, social insurance 
has great potential value for contributing to the general welfare of 
Haiti, supporting and complementing other measures to reduce sickness, 
poverty and insecurity. Haiti needs and should develop social insurance. 

These general conclusions from the study are strongly supported 
by testimony from many groups and individuals that were consulted. There 
is an almost surprising unanimity of opinion among officers of the 






- 130 - 


Governmentenployers, labor leaders, educators, physicians and others 
in many walks of life that Haiti needs and should undertake a program 
of social insurance. There are differences of opinion among them, but 
these are focused only on certain important details of the program— 
initial scope and content, particular methods of rdministraticn, etc. 

Despite great difficulties that have to be met and overcome, 
especially deficiencies of resources that have to be made good, Haiti 
can implement its Social Insurance Law. 

The Law is modest in scope; it proposes only insurance against 
work injuries and against the wage losses and medical costs of sick¬ 
ness and maternity. It does not attempt other forms of social insur¬ 
ance; and it does not attempt a general program of public assistance. 
The limited scope of the program is sound in relation to Haiti's 
limited resources. 

The systems of work-accident insurance and sickness-rrr ' ernity 
insurance proposed by the Law apply to only a sma"l fraction of the 
populati n-~to those who are wage and salary earners in commerce, 
industry, agriculture, private teaching, domestic service, rr ' public 
employment, and to certain of their dependents, and not to tbs much 
larger part of the population self-employed in agriculture or other 
enterprises. Nevertheless, even these limited systems cannot be 
safely undertaken in toto from the outset because Haiti has substan¬ 
tially no background of public familiarity with insurance, :'t has 
almost no personnel prepared for administration of social insurance, 
and it h s serious deficiencies in the medical resources essential 
for the provision of medical benefits under the insurance systems. 

Haiti would therefore be vise to start with only a fart of its 
modest soc: a insurance program, and only after an introductory period 
in which it c^nld prepare the public for participation in the program, 
train a nuc s of administrative personnel, and augment its medical 
resources. en, with the accumulation of operating experience and 
with the vi orous prosecution o. further developmental pirns, it 
could safely expand its social insurances. 

R ecommendations 


General 


le riti's limited resources advise that socia? insurance 
should bo inaugurated on a minimal scale and where the conditions are 
most favorable. The limitati^ s can be most readily overcome in the 
ort-au-P nee area, and the b ginning should be made there. Deficien- 
les in hospital and clinic faci Lties and in medical personnel are 
among the most important and among the slowest to overcome. The 





- 131 - 


initial insurance program should therefore be such as will involve 
minimal additional demand upon the medical resources—until they can 
be augmented 5 the initial insurance program should be one vjhose medical 
needs can be most readily met in the initial and early years of 
operation. 

2. There are many advantages in inaugurating both work-accident 
and sickness-maternity insurance simultaneously. But there are also 
serious disadvantages, especially because of the limited resources and 
the problems involved in preparing the public for participation. Haiti 
can start with one insurance system, rather than two, without sacrific¬ 
ing essentials. It will be easier in many respects to start Ydth work- 
accident insurance, and the social insurance program should be limited 
at the outset to this system. Sickness and maternity insurance should 
be inaugurated later, after one to three years of operating experience 
and after medical resources have been expanded. 

3. Any initial program, even limited work-accident insurance, 
should be undertaken only after a preparatory period which provides for 

(a) the performance of further surveys and studies, 
to furnish more reliable estimates of coverages, 
claims and costs than could be developed in this 
report, 

(b) the selection of personnel and their training in 
Haiti and abroad, 

(c) the preparation of a detailed plan of administration, 

(d) the development of medical resources (hospital, clinic, 
etc.) adequate for the program, and 

(e) the preparation and performance of an educational 
program directed to the public generally and to 
enployers and employees. 

The analyses in chapters VII and IX indicate that this preparatory 
period requires not less than a year before the Social Insurance Law 
is declared in force and collection of insurance premiums begins,and 
not less than 18 months before benefits become available to insured 
persons. 


4. The initial introduction of each social insurance program 
should be limited to Port-au-Prince and its immediate environs. It 
should then be extended to a wider surrounding area and to other parts 
of the country when experience justifies. Such extension should be 
effected as rapidly as practical, in order to achieve uniformity of 
treatment among the employers and errployees in each covered industry. 


- 132 - 


5. Insofar as practical, the specifications for work-accident 
insurance and sickness maternity insurance should be made similar or 
identical in the Law, o king toward the maximum coordination or 
eventual coalescence o the two insurances 0 By following this policy, 
Haiti can hope to achieve maximal simplicity for administration and 
for employer and employee participation—with a combined system of 
contributions and collections and without need, prior to provision 

of benefits, for determining whether a claim is or is not work- 
connected in origin. 

6. As noted before, the provision of the hospital, clinic 
and other medical benefits presents some of the most difficult 
problems for the social insurance program. Various alternative 
methods of providing these benefits are examined in chapter VIII. 

Each has advantages and disadvantages. A determining consideration is 
that the insurance administration should if possible avoid the need to 
build, equip, staff or manage medical facilities and services in the 
initial period, when it has so many other difficult problems to solve. 
In principle, it would be preferable for the social insurance system 
to arrange for the availability of these benefits by contract with the 
Department of Public Health, the latter assuming full responsibility 
for providing the required services in adequate quantity and quality. 
If the social insurance administration cannot have firm assurance of 
performance—as to quality as well as quantity—under such a contract, 
it should proceed to develop and operate its own necessary and 
sufficient medical resources e Experience under the limited program of 
the initial years should provide the basis for planning the prevision 
of medical benefits for the larger program of subsequent jrears—in 
Port-au-Prince and elsewhere. 

7. The construction and equipment of hospitals and clinics 
required for either work-accident insurance or sickness-raatrrnity 
insurance, or for both, (whether separate facilities or parts of 
general public hospitals), L-hr. Id if possible be financed by grants 
from the Government of Haiti, especially in the early years of social 
insurance. Such grants are justified by the contribute ,is which the 
insurance systems may be expected to make to the general welfare, and 
by the financial relief they will bring to the Government’ 1 s program of 
public hospital, clinic and medical care. If such grant . are not 
feasible, and the social ins ranee reserves are too small to permit 
investment in needed facil es, the Social Insurance Law should 
authorize IDASH to borrow t e needed money, with rep yi ent to be made 
on a capital-amortization basis out of current and future financial 
resources for the provision of medical benefits. 


- 133 - 


8o The Government of Haiti is considering the construction 
of a new general hospital in Port-au-Prince, If it proceeds with the 
plan, it should favorably consider having that institution prepared 
and equipped to provide hospital and clinic services to lJhe benefici¬ 
aries of the insurance systems (as well as to the general public), with 
3DASH reimbursing the Department of Public Health for services furnished 
as insurance benefits» Any plans for the preparation and construction 
of special facilities for, or by IDASH in the Port-au-Prince area should 
take account of this general hospital project,, 

9, Whatever plans are finally adopted for the provision of 
insurance medical benefits, they should be designed so as to give 
maximum practical support to programs for strengthening and improving 
the educational facilities for medicine, dentistry, pharmacy and 
nursing. 


10o Social insurance experience in many countries warns that 
the provision of medicines, appliances and related supplies as medical 
benefits can be very expensive and very difficult to keep within 
reasonable financial bounds, Haiti should not have to learn through 
its own experience that a substantial part of insurance income can be 
wasted on commodities which contribute little of real value in prevent¬ 
ing illness, accelerating recovery or minimizing disability,, In the 
case of work-accident insurance, this part of medical benefit should be 
limited to commodities which the attending physician or dentist regards 
as necessary for diagnosis, treatment or rehabilitation! in the case 
of sickness and maternity insurance, it should be limited to those 
commodities which deserve insurance provision because they are 
seriously expensive as well as medically important* The hospital and 
clinic facilities which provide insurance medical benefits should 
include pharmacies to supply medicines, appliances and related 
commodities that are included in a list prepared by IDASHo IDASH 
should also consider selling at cost, in these pharmacies, other 
similar commodities that are prescribed by the attending physician 
or dentist but are not in the list of items furnished as insurance 
benefits* 


11* The Social Insurance Law provides for administration through 
a more or less wholly autonomous institution (IDASH), As pointed out 
in chapter IX, this has been properly subject to criticism. The 
general pattern for IDASH should be modified so as to make it a semi- 
autonomous or a quasi-autonomous institution, coordinated with other 
departments of the Government 0 Two patterns of reorganization are 
presented in the text of the report. Plan A keeps HASH as an indepen¬ 
dent agency, but interlocks it with related Departments of the Govern¬ 
ment j Plan B locates IDASH within the Department of Labor, but preserves 
certain important advantages of the autonomous insurance institution. 

Plan A may be more advantageous, on balance, than Plan B for Haiti, 


* 134 - 


12o The programs contemplated by the Social Insurance Law would 
be insurance systems. Large numbers of employers and employees would 
participate, and they would have a direct and evident stake in the 
effectiveness and integrity of the operations. The President of the 
Republic and the Ministers most closely concerned (Labor, Public Health 
and Finances) should therefore give every possible aid to assure (a) 
selection of qualified administrative personnel for 3DASH, (b) tenure 
and security of-office on a merit basis, and (c) both economy and 
efficiency in administration. 

13. The initial social insurance program may have to be of 
very small size, for reasons given earlier, and it may not be 
economical to administer. A substantial part of its administrative 
expense should be regarded as a developmental cost for the larger 
program of future years, and this expense should be subsidized from 
Government grants, from insurance reserves,- or from both. 

14. The Social Insurance Law should include, with respect to 
both work-accident insurance and sickness-maternity insurance, a 
general financial guarantee by the Government of Haiti that would 
underwrite benefits, administration, loans, and the principal and 
interest-return of invested reserves. 

15. It is recognized throughout this report that the social 
insurance systems would apply to only a small proportion of the total 
population of Haiti even after insurance coverage is comprehensive. 

This results mainly from the exclusion of self-employed persons, 
especially those engaged in independent farm operation. Even with 
limited coverage, social insurance contributes to the welfare of non¬ 
insured persons by bringing in corn©-security to the insured persons 
and by strengthening the nation 9 s resources for personal health 
services. Nevertheless, the inauguration of social insurance for 
wage and salary workers invites renewed attention by the Government, 
especially if it subsidizes the insurance systems, to measures that 
will contribute to the welfare of the non-insured population. This 
applies particularly to measures for the expansion and improvement 

of health services for the rural population. 

16. In view of the difficulties encountered in this study, and 
the continuing uncertainties in some of the basic statistical and 
financial data, new surveys and analyses should be undertaken as soon 
as possible to provide more, and more reliable, information for social 
insurance planning. Such surveys should accumulate more detailed and 
more comprehensive information on the sectors of the labor force which 
may be involved in work-accident insurance or in sickness-maternity 
insurance. They should cover: Employment and turnover; family compo¬ 
sition; earnings; prevalence and incidence of sickness, accidents and 
injuries—by cause, duration, characteristics of the individual, and 


- 135 - 


by receipt of care and expenditures therefor$ and resources for medical 
services furnished in the hospital, the clinics and the home. 

17. The present and prospective work of the Bureau of the Census 
is very important for social insurance planning and operation, as well 
as for Haiti generally, and it should be actively supported. IDASH 
should encourage the Bureau to equip itself for the performance of 
special sample censuses, surveys, and statistical studies useful to 
the social insurance program. 

Work-Accident Insurance 


18. If there is any ambiguity in the Social Insurance Law, it 
should be made entirely clear that work-accident insurance (workmen’s 
compensation) assumes responsibility for compensation and service 
benefits in cases of work-accident or injury, and that the Law relieves 
the covered employer of liability in such cases. However, since the 
Law of May 5, 1948 (arts. 10, 11) now requires employers to pay sick- 
leave wages at full rate for a maximum of 15 days in a year, and this 
is at a higher rate than social insurance compensation, the Social 
Insurance Law may retain this more generous provision and exclude it from 
the general relief given employers with respect to employer liability. 

19. The Social Insurance Law authorizes IDASH to postpone the 
availability of benefits for six months after the Institute begins to 
function (art. 86). This is intended to provide an unique preliminary 
period for the inauguration of administration and the accumulation of 
insurance operating funds. It is not intended to be a period in which 
the insurance system takes over responsibility for compensation and in 
which the employer is' relieved of liability for work accidents or 
injuries. The Law should make clear that while such cases occurring in 
this preliminary period may be made reportable, to initiate the system 
of accident reporting and prevention, the employer is not relieved of 
liability with respect to accidents or injuries occurring within this 
period. 


20. Because of the probable administrative difficulties, the 
initial coverage of work-accident insurance should exclude domestic 
servants and farm laborers. However, coverage should be extended to 
these groups as soon as IDASH is confident it has devised practical 
administrative procedures and has arranged for the ready and adequate 
availability of medical benefits. 

21. The administration of temporary disability benefits under 
workmen’s compensation should be simplified by being paid with respect 
to the injured worker only, without reference to his dependents. Pro¬ 
vision for dependents’ benefits should be made later, when more compre- 



- 136 - 


hensive information is available on family composition of covered 
workers and when IDASH has had' sufficient experience with claims, 
awards, payments and. reviews to'undertake the administrative 
’complexities that will probably be involved in paying dependents* 
•benefits in cases of temporary disability, 

• % s ■ i < 

22 0 The specifications in the Social Insurance : Law should be 
clarified so that in case of total disability (tenporary or permanent), 

- cash.benefits are payable only with respect to any day"or other 
period 1/ in which the disabled worker does not engage in any gainful 
work, whether or not his employer pays him voluntary sick pay or 
voluntary supplement to insurance benefit. 

» ** * . * * 

23„- The cash benefits of work-accident insurance are intended 
as total or partial replacements of wage loss resulting from work- 
connected incapacity or death, Lunp-sum settlements in lieu of periodic 
cash payments may be dissipated, leaving the beneficiary without income 
security. Such settlements should be made sparingly and conservatively, 
except when made for administrative convenience in settling very small 
awards. 

‘ ' • • 

24, On the basis of the limited information discussed in 
chapter VI, the initial premium for work-accident insurance should be 
uniformly 1 percent of total payroll of each covered employer (includ¬ 
ing “in ( ’’total payroll 1 * all payments as compensation, of whatever form). 
With respect to each of the first two or three benefit years, this, 
'initial* premium rate should be subject to retroactive upward adjustment 
by assessment, ori the basis of actual total experience $ but such 
assessment, if any, should be at a uniform rate not to exceed the . , 
initial premium rate of 1 percent of payroll. With r.espect to each 
subsequent*benefit year and until such time as IDASH finds graduated 
premiums necessary, the insurance premium should be at a fixed uniform 
rate for all covered employers. This rate should be determined annually 
on th<6 basis of expected average cost for the year, and it should be 
subject to* a uniform adjustment which may be an additional assessment 
for bhat year or a credit toward the premium of the following year. 

If graduated premiupis are found necessary, IDASH should consider a 
minimum number of industry rates in (for example) l/4- or l/2-percent 
brackets, in lieu of widely varied experience rates for industries, 

employers or establishments. 

! . ^ * • *• # \ • 

s f \ * , 

25. In order to encourage econony and efficiency of administra¬ 
tion', the Social Insurance Law should provide that IDASH may not in 
any fiscal year spend’for administration of work-accident insurance an 
amount, chargeable to funds derived from insurance premiums, in excess 


1/ Except with respect to (a) the 15 days in which an employer is 
obligated* under the Law of May 5, ! 1948 ( 4rt e 10) to pay sick pay, 
and (b) the insurance waiting period. " 



- 137 - 


of a fixed percentage of such total premiums. The percentage should 
be (say) 25 percent with respect to each of the first 3 years, and 
(say) 20 percent with respect to each succeeding year. Administrative 
expenses here refer to both direct costs of current operations and a 
fair annual share of multi-year expenditures for buildings, durable 
equipment and supplies. Administrative expenses in excess of these 
limits should be permissible only if subsidized out of IDASH reserves 
or Government subsidy, because incurred for developmental purposes 
in an early period when the insurance system has very limited 
coverage. 

26„ For reasons given in chapter VI, the work-accident 
insurance law should not permit the self-insurance or the “contracting- 
out’ 1 of covered employers. 


Sickness and Maternity In surance 

27. Sickness and maternity insurance should be instituted in 
the Port-au-Prince area after IDASH has accumulated necessary admin¬ 
istrative experience under work-accident insurance (see recommenda¬ 
tions 1 and 2, above). It should be undertaken only after performance 
of the necessary educational program and only after IDASH has assured 
the availability of adequate resources for provision of the medical 
benefits. When sickness and maternity insurance begins, its coverage 
should be the same as that which is in force for work-accident 
insurance at the time. 

28. The Law should be clarified to assure that IDASH is 
authorized to undertake sickness and maternity insurance in stages 
with respect to employment coverage, geographical location, and scope 
of benefits—these three factors being taken severally or in combin¬ 
ations. The authorization should permit IDASH to reduce the total insur¬ 
ance contribution rate with respect to any coverage or period of time 
for which the scope of benefits is less than the total specified in 

the Law, and such reduced rate should be reasonably related to the 
cost of the benefits being provided. 

29. The Social Insurance Law provides for voluntar y insurance 
of dependents of insured employees. For the reasons given in chapter 
V, this is unwise and financially dangerous. The Law should be 
amended to provide for the c om pulsory insurance of dependents| but 
this compulsory insurance should not come into force automatically 
when the compulsory insurance of employees is instituted. IDASH 
should be authorized to determine when compulsory coverage of 
dependents comes into force. Until such time as IDASH has reliable 
statistical information about dependents, and is administratively 
prepared to cover them, sickness and maternity insurance should 
cover only employees. 





- 138 - 


30o In view of the urgent need for improved medical care for 
mothers and children, sickness and maternity insurance should be 
extended as rapidly as practical to domestic servants, especially 
with respect to maternity care and medical services for infants and 
other minor dependents,, 

31o Favorable consideration should be given to coverage (for 
medical-benefits) of the dependents of officers and enlisted men of 
the Garde d*Haiti, with periodic reimbursement to IDASH by the 
Government for the costs of benefits and administration incurred cn 
their behalf. 

32. The inadequacy of statistical information concerning 
earnings, continuity of employment and turnover, and other factors 
makes it necessary that the Social Insurance Law should start with 
rather conservative eligibility requirements,. This is especially 
important for any period in which coverage is limited. r, ithout 
such requirements, the insurance system may find itself obligated 
to furnish benefits to many more persons than the insurance finances 
can afford. Experience may show, however, that initially conservative 
eligibility requirements are unduly severe and restrictive. The Law 
should therefore authorize IDASH to reduce such eligibility require¬ 
ments for medical and cash benefits by (say) not to exceed one-half 
of the number of required contributions in a contribution period when 
it is satisfied, on the basis of operating experience, that such 
liberalization is desirable and practical without endangering the 
finances of the sickness ind maternity insurance. 

33o In the interest of simplifying the .administration of 
sickness and maternity insurance, cash sickness benefits should be 
paid only with respect to employees. Provision for benefits w r hich 
take account of employees 3 dependents should be made later, after 
more comprehensive information is available on family composition 
of covered workers, and Then IDASH has had sufficient experience 
with claims, payments and reviews to be justified in undertaking the 
additional complexity of administration. 

34® To achieve simplification of administration and reduction of 
costs, without sacrifice of reasonable adequacy, the specifications for 
ca w sh sickntsH benefit under sickness and maternity insurance should be 
amended so that it is payable (a) only after a waiting period of 7 
(instead of 4) consecutive calendar days, (b) for a maximum of 26 weeks 
in a year (instead of for an indefinite period), and (c) only with 
respect to any day or other period 2/ in which the incapacitated employee 
does not engage in any gainful work, whether or not his employer pays him 
voluntary sick pay or voluntary supplement to insurance benefit. IDASH 

2/ Except with respect to (a) the 15 days in which an employer is obliga- 
ted under the Law of May 5, 1948 (art. 10) to pay sick pay, (b) the 
insurance waiting period, and (c) incapacity after the 26th benefit 
week. 




- 139 


may be authorized to liberalize the specification for the waiting 
period, within stated limits, when experience shows this is desirable 
and feasible, 

35. In view of the uncertainties that will attend the operations 
of sickness and maternity insurance in the first years, the La- r should 
be amended so that cash sickness and cash maternity benefits : hould be 
payable at the rate of 50 percent of basic wage (without allowances for 
dependents as in the Law) and so that the cash death benefit should be 
equal to the monthly basic wage (instead of three times as much). 
However, IDASH should be authorized to increase the rate for cash 
sickness and cash maternity benefits to 67 percent -when experience 
warrants and the finances of the insurance system permit, 

36. The Law provides for the compulsory coverage of only those 
employees who have earnings up to 0300 per month. As found in chapter 
V, this is unculy restrictive in its effects on coverage and finances. 
The specifications for sickness and maternity insurance should be 
amended so that (a) compulsory coverage applies to all employees 
(including officers) of covered employers, regardless of earnings rate 
or amount, and (b) contributions are payable with respect to earnings 
up to 0500 a month. If these amendments are made, the provision for 
voluntary insurance of employees with earnings in excess of a limit 
specified for compulsory coverage should be eliminated. 

37. The Social Insurance Law should be amended to make the 
Government contribution to sickness and maternity insurance explicit, 
and to fix it at (say) one-third of the total cost. If this proportion 
is not feasible, the Government’s share might, as a minimum, be fixed 
as an amount equal to the cost of administration (15 percent or less 

of the total annual cost), and take the form of an annual advance 
payment based on budget estimate, with an annual retroactive adjustment 
of such cost. 

38. The financial analysis in chapter V indicates that, if 
recommendations ^3, 24, 15 and J36 are adopted, the total contribution 
rate for sickness and maternity insurance should be fixed at 4 percent 
with respect to insurance of covered employees,2/ "Whether the insurance 
costs are divided among employers, employees and the Government, or 
between employers and employees, the employer should be obligated to 
pay three-fourths of the total payable by both employer and employee 
with respect to employees earning less than 0150 a month, and all of 
such total with respect to employees earning less than 0110 a month, 

39. Similarly, the financial analysis in chapter V indicates 
that, if recommendations 29, 33, 34, H and 36 are adopted, the total 
contribution rate for sickness and maternity insurance should be fixed 


2/ Instead of the 8-percent rate now in the Social Insurance Law. 




- 140 - 


at 7 percent with respect to covered employees and their qualified 
dependents if it is found, from further surveys, that there may be as 
many as 2 qualified dependents per insured employee; otherwise, if 
there may be substantially fever than 2 dependents per employ es, the 
rate should be fixed at 6 percent.^/ 

40. Provision should be made for periodic valuation of the 
equity relations between contributions and benefits in' sickness and 
maternity insurance, to provide a basis for the periodic adjustment 
of the contribution rates and of the limit on the amount of monthly 
earnings subject to contributions. 

41* In order to encourage economy and efficiency of administra¬ 
tion, the Social Insurance Law should provide that IDASH may not in 
any fiscal year spend for administration of sickness and maternity 
insurance an amount, chargeable to funds derived from insurance 
premiums, in excess of a fixed percentage of such total premiums. The 
percentage should be (say) 20 percent with respect to each of the 
first 2 years, and (say) 15 percent with respect to each succeeding 
year. Administrative expenses here refer to both direct costs of 
current operations and a fair annual share of multi-year expenditures 
for buildings, durable equipment and supplies. Administrative expenses 
in excess of these limits should be permissible only if subsidized out 
of IDASH reserves or Government subsidy, because incurred for 
developmental purposes in an early period when the insurance systems 
have very limited coverage. 


4/ Instead of the 13-percent rate now in the Social Insurance Law 
(8 percent for the employee and 5 percent for the dependents). 







APPENDICES 


A« The Social Insurance Law of October 1949 

Bo Work Accidents and Compensation on Three 
Sisal Plantations 

C. 


Appendix Tables 1-19 













Appendix A 


Text of the Social Insurance Law, October 1949 


Source: l£ Moniteur , Journal Qfficiel of the Republic of Haiti. 
No. 113, Port-au-Prince, Monday, November 7, 1949. 


A 


Summary 

Law founding an autonomous 
social insurance institution 
with juridical personality 
named the "Social Insurance 
Institute of Haiti" 


LAW 

DUMARSAIS ESTTME 
President of the Republic 


Considering Article 61 of the Constitution; 

Considering the law of August 10, 1934 on working conditions 
amended by the law of September 5, 1934 and the decree-laws of 
May 4 and September 24, 1942 and by the law of May 5, 1948; 

Considering decree No. 268 of May 15 , 1943 determining the 
operating conditions of the Social Insurance Fund; 

Considering that it is the duty of the State to protect the 
worker against the risks inherent in his condition; 

Considering that, in order to guarantee him the maximum of 
security, it is important to organize social insurance; 

Acting on the report of the Secretary of State for Labor; 

And after deliberation of the Secretaries of State in 
Council; 






A-2 


Proposed 

And the Legislative Body passed the following lows 

Art. 1. There is hereby established an autonomous social 
insurance institution having juridical personality# It shall be 
named the “Social Insurance Institute of Haiti” and may also be 
known by the abbreviated form “IDASH". 

Art# 2# The purpose of IDASH is to administer social 
insurance according to the principles of the present law# 


I 

Definitions 

Art* 3« For the purposes of the present law, the following 
terms and expressions shall be used in the sense indicated below, 
namely? 


(a) The term “employer” means the natural or juridical person 
who, in the exercise of any activity, uses the services of another 
person in return for compensation, under an actual or implied work 
contract. 

Ihe State, the communes, and other public organizations shall 
be considered as employers in relation to their employees# 

A contractor shall be considered as an employer and jointly 
with the principal employer shall fulfil the obligations of the law# 

(b) The expression “industrial accident" means any bodily 
injury caused by or in the course of work. 

(c) The expression "basic wage” means the wage received by 
the employee or worker exclusive of compensation for overtime work. 
In the case of an employee or worker paid by the piece, the basic 
wage shall be considered as the average wage paid during the three 
months preceding the accident or the sickness, or during the days 
already worked, if the length of time worked is lees than 3 months# 

(d) The expression “disability" means the impossibility for 
an employee or worker to continue performing his service because 
of sickness or an industrial accident. 



A-3 


Disability may be temporary or permanent. 

Permanent disability may be partial or total. 

(e) Ihe term ’’dependents’ 1 means: 1. Ihe legitimate -wife of 
the insured person or the concubine who has lived with him as a wife 
during the five years preceding the illness, disability or accident, 
provided that both have, during their life together, been free from 
all bonds of marriage; 2« The legitimate or acknowledged natural 
children of the insured who are under 16 years of age. 


II 

Field of Application 

Art. 4<> Social insurance as instituted by the present law 
covers the risks of sickness, maternity, and industrial accidents. 
However, the Council of Administration shall be authorized to 
introduce compulsory insurance by degrees, taking into account; 

1. The possibility of registering the employers and workers 
to whom the insurance applies; 

2o The possibility of collecting the contributions; 

3» The possibility of effectively giving the services and 
benefits provided for in the present law. 

A® Compulsory Insurance 

Art® 5. The following persons must be insured when their 
basic monthly wage does not exceed 300 gourdes: 

1® Employees of the State and of administrations controlled 
by the State (communes, banks, etc.)® 

2® Employees, workers, day-laborers in agricultural, 
industrial, and commercial enterprises, and in general all manual 
or intellectual workers who, for compensation, render their services 
to an employer under an express or implied work contract. 

3® Ifcachers and supervisors in private teaching establishments. 

4® Domestic personnel paid in kind or in cash. 




A-4 


Art. 6. The following persons shall be exempt from 
compulsory insurance: 

1. A husband or wife who works solely for the account of 
his or her spouse, and children under 18 years of age who work 
for their father and mother, at home, without receiving a cash 
wage determined in advance. 

2. Aliens employed in the embassies, legations, or 
consulates of their respective countries, and technicians whose 
stay in Haiti does not exceed one year. 

3* Military personnel on active duty. 

4. Clergymen serving in the ministry. 

B. Optional Insurance 

Art. 7. Insurance shall be optional for any employee or 
worker mentioned in Art. 4 above whose monthly wage exceeds 
300 gourdes. 

However, when the basic wage of an insured person exceeds 
500 gourdes, solely the latter amount shall be considered in 
calculating contributions and benefits. 

Art. 8. At the time of registering for optional insurance, 
the person concerned shall establish that he does not have any 
ailment which affects or may affect his ability to work. 

Art. 9* By special regulations IDASH shall determine: 

1. The conditions of voluntary continuation of the insurance 
of persons who cease to be subject to the obligation to be insured; 

2. The age at which liability to compulsory insurance shall 

cease. 

Art. 10. An insured person who is deprived of paid employ¬ 
ment and ceases to be insured shall retain for 6 months his right 
to the allowances in kind of sickness and maternity insurance. 


A-5 


III 

Organization and Operation 

Art. 11 o IDASH shall be managed by a Council of Adminis¬ 
tration composed of 9 members, as follows:- 

3 representatives of the Government from the Departments of 
Labor, Public Health, and Finances, respectively; 

3 representatives of the employers; 

3 representatives of the workers. 

Art* 12. The representatives of the Government shall be 
chosen directly by the President of the Republic from among the 
members of the technical personnel of the afore-mentioned 
departments * 

The representatives of the employers and the workers shall 
also be appointed by the President of the Republic from two lists 
of nine members each submitted by the existing employer organizations 
and the labor union federations and legally recognized nonfederated 
labor unions. The same lists may also be used in the cases provided 
for in Art. 15 of the present law. 

The members of the Council of Administration shall be 
irremovable; their term of office shall be for 3 years and may be 
renewed indefinitely. 

Art. 13. The members of the Council of Administration shall 
not simultaneously hold the office of Director or Assistant 
Director of IDASH. 

The same prohibition shall apply to persons related to each 
other or to the Director or the Assistant Director of IDASH by 
blood or marriage up to the third degree inclusive. 

Art. 14. The folloTdng shall automatically cease to serve 
on the Council of Administration: 

1. Any member who for more than 1 year has been unable to 
perform his functions by reason of physical or mental disability 
or absence. 

2 0 Any member who has submitted his resignation to the 
Council of Administration. 



A-6 


3a Any member who has been pronounced legally incompetent. 

Arto 15* In the aforesaid cases as well as in case of death, 
the Council of Administration shall give notice of the vacancy to 
the President of the Republic, who shall appoint a successor within 
one month in the manner prescribed in Art. 12 of the present law. 

The successor shall hold office until the expiration of the 
term of his predecessor. 

Art. 16. The duties and responsibilities of the Council of 
Administration shall be as follows: 

1. To elect from among its members each year a Chairman and 
a Vice Chairman who shall replace the Chairman in case of inability 
to act; 

2 0 To appoint the Director and the Assistant Director of 
IDASH and to relieve them of their functions under the conditions 
prescribed by the present law; 

3° To establish regulations determining the duties and 
powers of the Director; these regulations shall contain a list of 
questions the solution of which shall be exclusively within the 
province of the Council of Administration; 

4® To control the operations of the Director, approve the 
reports, general balance-sheets, and budgets of expenses which he 
presents to it, and to make such changes and additions therein 
as are deemed necessary; 

5. To establish all regulations necessary for the functioning 
of IDASH* 

Art* 17* The Council of Administration shall meet at least 
once a year and whenever convened at the instance of its Chairman 
or the request of three of its members or the Director of IDASH* 

Art* 18* The Council of Administration may appoint one or 
more Assistant Directors to aid the Director of IDASH in his task, 
according to the needs of the institution® The choice of Directors 
and Assistant Directors may be made only by a two-thirds majority 
of the members of the Council of Administration* 

Art® 19* The Director of IDASH shall handle all the affairs 
of the institution except those which, by reason of their importance, 
require the intervention or approval of the Council of Administration 

♦ 


A-7 


and are provided for in the regulations fixing the powers and duties 
of the Council® He shall annually present to the Council of Admin¬ 
istration the balance-sheet and the report on the preceding fiscal 
year, as well as the work program for the following fiscal year. 

The Director shall not be relieved of his functions except for serious 
reasons following an investigation during which his defense shall 
be heard® 

Art. 20. The Director of IDASH shall have the following 
powers in particular: 

1. To manage and administer the institution; 

2. To appoint and dismiss members of the personnel of IDASH; 

3o To prepare the annual budget and to authorize expenditures 
under the budget approved during the year; 

4® To make arrangements with doctors, hospitals, etc.; 

5* To perform all acts susceptible of ensuring the 
prosperity of the institution; * 

6. To attend the meetings of the Council of Administration, 
at which he shall act in an advisory capacity. 


IV 

Financial Resources and Organization 

Art. 21. The resources of IDASH shall be constituted by: 

1. Contributions paid by employers and workers under the 
present law; 

2. Interest and income of all kinds produced by the movable 
and immovable property of IDASH; 

3. Donations, legacies, and subsidies in favor of IDASH; 

4. All other receipts which may be provided for by the 
laws and regulations in favor of IDASH; 

5. The proceeds of the fines imposed by IDASH; 

6. A subsidy, the amount of which is to be determined later, 
which the State shall grant to IDASH* 



Arte 22. The insurance contributions and cash benefits 
shall be computed according to the basic wage of the insured. 

IDASH may group the insured in a limited number of wage classes 
with an "insured wage" in each class * 

Art. 23, If the worker receives food or lodging in addition 
to a cash wage, his wage shall be considered as increased by 
25 percent; if he receives both food and lodging, his wage shall 
be considered as increased by 50 percent. 

Art. 24 . For compulsory insurance in case of sickness and 
maternity the rate of contribution shall be fixed at 8 percent 
( 8 %) of the basic wage of the insured person, one-half of this 
amount being a charge on the employer. 

If the basic monthly wage of the insured person is less than 
110 gourdes, the contra.bution shall be entirely a charge on the 
employer. 

Art. 25 . For optional insurance the rate of contribution 
shall be fixed at 6 percent of the basic wage. 

This contribution shall be paid directly by the insured in 
the manner prescribed by IDASH* 

Art. 26. Insured persons who desire to extend to their 
dependents the benefits of medical and pharmaceutical aid mentioned 
in Articles 52 and 60 of the present law shall pay a supplementary 
contribution equal to 5 percent of their basic wage. Hiis contri¬ 
bution shall be entirely a charge on them* 

Art. 27. Employers, after registration and after regularly 
registering their employees and workers subject to compulsory 
insurance in the manner and within the time-limits prescribed by 
the regulations of IDASH, shall pay their contributions to this 
institution by special insurance stamps which shall be affixed in 
the individual insurance booklets, or in cash, in the latter case 
presenting their pay books. 

Art. 28. It shall not be necessary to register a compulsorily 
insured person who enters the service of a new employer if his 
former employer registered him and if he gives proof thereof by 
presenting his insurance booklet. In such case the new employer 
shall notify IDASH of the name and surname of the insured person and 
the number of his booklet. 


A-9 


Arte 29* All employers shall be obliged to keep uneir pay¬ 
rolls in the form to be prescribed by IDASH and to retain them for 
two years o IDASH may at any time have such pay sheets examined by 
its qualified inspectors. 

In the event of failure of employers to keep regular payrolls 
and to retain them for the period specified above, IDASH may itself 
fix the amount of the contributions owed by employers in default, on 
the basis of previous contributions or any other information enabling 
it to determine an equitable amount© In the absence of any information, 
IDASH may fix the rate of contribution on the basis of the maximum 
compensation assumed to be paid for the employment in question© 

Art© 300 Employers shall be responsible for the payment of 
contributions due from the M compulsorily insured persons” who work 
for them© In order to comply with this provision, employers shall, 
in paying wages, be authorized to deduct the contributions to be 
paid by the insured® In the event of their failing to do so in 
time, they may not deduct at one time more than 3 contributions due, 
payment of the others being their responsibility* 

In case of delay in the payment of contributions, employers 
shall*pay IDASH 12 % interest annually on the unpaid amounts, in 
addition to the fine provided for in Art® 64 of the present law© 

The obligation to pay the contributions shall prescribe 
after 5 years© 


V 

Insurance - Work Accidents 

Art© 31* Insurance against industrial accidents shall be 
administered in a special section; it shall have separate accounting 
and its own resources© 

Art. 32© The following shall not be considered as work 
accidents and shall not consequently give right to benefits3 

1© Accidents occurring when a Y/orker is in a state of 
intoxication; 

2® Accidents which a worker deliberately causes; 

3© Accidents resulting from a punishable misdemeanor, an 
attempt at suicide, or a brawl in which a worker voluntarily 
takes part© 



A-10 


The state of intoxication as well as the deliberate 
provocation and the voluntary participation provided for in 
paragraphs 1, 2 and 3 of the present article shall never be 
presumed and must clearly be established. 

Art. 33* Insurance against industrial accidents shall extend 
to all employees and workers referred to in Art. 5 of the present 
law, without any distinction based on age or the amount of wage. 

The cost of this insurance shall be borne solely by the employer. 

Art. 34* Ihe initial rate of the contribution of employers 
for industrial accident insurance shall be fixed at 1 percent of 
the basic wage of the employees and workers. IDASH may change 
this rate with due regard for the risks inherent in the enterprises 
considered and the security measures taken by the employers. 

Art. 35* In case of industrial accidents, the insured shall 
be entitled to medical, surgical and pharmaceutical aid, hospital¬ 
ization, medicines, and the necessary prosthetic and orthopedic 
appliances. 

Medical aid shall not cease until the injured person has 
completely recovered. The extent of such aid shall be determined 
by the regulations of the Council of Administration. 

Art. 36. In case of disability, the insured victim of an 
industrial accident shall be entitled to daily compensation 
beginning on the fourth day after the accident and continuing 
during the period of his disability. 

Art. 37. All industrial accidents causing a disability of 
one day or more shall be reported to IDASH in accordance with the 
procedure prescribed by IDASH. 

Art. 38® In case of disability, the insured person shall 
be entitled until the end of medical aid to a cash allowance equal 
to 50 percent of his basic wage for each work day. This allowance 
shall be increased for insured persons with dependents at the rate 
of 10 percent of the valuation base for each dependent and up to 
70 percent of the insured wage. 

Art. 39* In case of total permanent disability the insured 
person shall be entitled to a monthly pension equal to two-thirds 
of his wage; in case of permanent partial disability the insured 
person shall be entitled to a monthly pension which shall be in 
proportion to the degree of his disability. 


A-'ll 


Art* 40<> The degree of disability shall be established 
according to the nature and seriousness of the injury. IDASH shall 
adopt a fixed scale containing the various injuries and the 
corresponding degrees of disability. 

Art. 41* Tine pensions shall be paid in the same manner as 
wages, and the recipients shall, at the request of IDASH, submit to 
periodic reviews of their disability. 

Art. 42. If the disability is less than 25 percent, IDASH 
shall pay to the injured person, according to the fixed scale, 
instead of the pension, a single cash indemnity the amount of which 
shall be determined by the Council of Administration. 

Art. 43» In case of disabilities of 25 percent or more, 

IDASH may also pay a cash indemnity instead of the pension. 

However, this form of compensation shall not apply to victims of 
accidents until the disability is stabilized. 

Art. 44® Ihen an accident results in the death of the 
insured person, the following benefits shall be accorded? 

1. A funeral benefit in an amount equivalent to one month 
of the basic wage or to the basic wage of the last four weeks, to 
the dependents of the insured; 

2. A pension equivalent to 50 percent of the pension to 
which the insured would have been entitled in case of permanent total 
disability, to the widow of the insured; 

3. In the absence of a legitimate spouse, 30 percent of 
this same pension to the woman who lived with the insured, as a 
wife during the five consecutive years immediately preceding his 
death, provided that both were during their life together, free from 
all bonds of marriage; 

4. A pension equivalent to 20 percent of the pension to 
which the insured would have been entitled in case of permanent 
total disability, to each of the legitimate or acknowledged natural 
children if they are under 16 years of age, the right to such 
pension being lost when a beneficiary reaches this age. 

Art. 45. A woman with a widow's pension who contracts 
marriage shall lose her right to the pension. 

Art. 46. An orphan's allowance, separately or together with 
that of the mother, shall not exceed 80 percent of the pension to 
which the insured would have been entitled in case of permanent, 
total disability. 


A-12 


Art. 47* An employer who has insured the workers .in hi s 
employ pursuant to the regulations of the present law shall bo 
relieved of the obligations contracted by him in case of industri.il 
accidents, by virtue of thus provisions of the Civil Code 0 

Art* 43o If it is proved that an employer personally provoked 
an accident or that he was the cause thereof through serious fault 
or obvious negligence, IDASH may require him to reimburse in full 
the benefits paid and the expenses in cash and in kind incurred in 
compensation for the accident. 

Art. 49* When the insured, in the course of work, suffers 
an accident under such circumstances as to result in a right to 
take action against a person other than his employer, IDASH shall 
automatically be subrogated to the rights of the victim or his 
dependents or heirs in the exercise of such right of action. 

Such subrogation shall not relieve IDASH of its obligations 
under Articles 35, 33 and 39 of the present law. The amount of the 
damages obtained from the responsible third person shall, after 
deduction of the court costs and the compensation granted by IDASH, 
be paid to the insured person or his dependents. 

Art. 50o State employees or others who are victims of an 
industrial accident shall not be entitled to the cash benefits of 
insurance as long as they retain their wage. 

If they receive only part of their wage and the amount 
thereof is less than that of the cash benefits to which they are 
entitled, IDASH shall pay the difference. 


VI 

Sickness Insurance 


Art. 51» In case of sickness the insured shall be entitled 
to medical and pharmaceutical aid, hospitalization, and to 
compensation in cash. 

The rules of procedure of IDASH shall determine the 
appropriate measures for avoiding abuses. 

Art. 52. The dependents of insured persons who have paid 
the contribution provided for in Art. 26 of the present law shall 
likewise be entitled to medical and pharmaceutical aid and to 
hospitalization« 



A-13 


Art. 53* Medical aid shall be given to the insured from 
the beginning of sickness, for a maximum period of 27 weeks, and to 
their dependents for a period of 13 weeks* 

However, IDASH may extend this period to one year in special 
cases such as prolonged convalescences. 

Art* 54* The insured shall receive medical care in the special 
dispensaries of IDASH insofar as possible, and those whose condition 
requires hospitalization shall be placed in serai-private rooms of 
the public hospitals or in the private hospitals with which IDASH 
has concluded a contract for such service, or in hospitals belonging 
to IDASH. 

Insured persons desiring to be hospitalized in private rooms 
shall themselves pay the difference between the hospital rate for 
a private room and that of a semi-private room. 

Art. 55® In case of sickness resulting in disability, an 
insured person shall be entitled to a cash allowance equal to 
50 percent of his basic wage, for each work day. To be entitled to 
such allowance, the person concerned must have been insured for 
six months and the insurance contribution must have been withheld 
for seventeen weeks. The insured person shall be entitled to these 
benefits beginning on the 5th day of his sickness, and for the 
duration of his disability. However, in case of relapse, no further 
waiting period shall be required. 

Art. 56. The sickness allowance shall be increased for an. 
insured person with dependents at the rate of 10 percent of the 
valuation base for each dependent and up to 70 percent of the 
insured wage. The names of these dependents must be entered on the 
insurance card of the person concerned. 

Art. 57. The insured shall be deprived of the cash allowance 
provided for in the preceding articles if it is well established 
that he deliberately provoked, the sickness. 

Payment of benefits shall be suspended: 

1. Yfhen the insured person receiving them performs work 
for which he is paid; 

2. When he refuses to carry out the.instructions of the 
doctor attending him. 


A-14 


Art« 58. Insured persons shall not be entitled to cash 
benefits as long as they receive a wage* If they receive only part 
of their wage, the amount thereof shall be deducted from the amount 
of the allowances provided for in the present law. 


VII 

Death Allowance 


Art. 59« littien sickness results in the death of an insured 
person, a death benefit equivalent to 3 months’ basic wage or the 
basic wage of the last 13 weeks shall be paid to his beneficiaries. 

This allowance shall be paid to the surviving spouse or the 
descendants, or in the absence thereof, to the ascendants who were 
supported by the insured at the time of his death. 

The death benefit shall be paid only to beneficiaries of 
insured persons who have been registered with IDASH for at least one 
year and have contributed for at least 240 days. 


VIII 

Maternity Insurance 

Art. 60. For pregnancy and confinement IDASH shall grant the 
insured worker medical, obstetrical and pharmaceutical aid; and 
hospitalization at the explicit request of the doctor in attendance. 

Art. 61. The cash benefits of maternity insurance shall be 
the same as those of sickness insurance. They shal3 be accorded to 
the insured regardless of the legal status of the child. 

Miscarriages and the results thereof shall give rise to 
sickness benefits. Criminal abortion shall not entitle the insured 
person to cash benefits. 

Art. 62. Compensation shall be payable only for the 42 days 
preceding or following confinement. Payment of the compensation 
shall be suspended if during this period the insured person receives 
other benefits in the form of a sickness allowance or if she continues 
to receive a wage. 

However, the insured person shall not be entitled to compen¬ 
sation for the days during which she performed paid vrork other than 
domestic work consistent with her condition. 




A-15 


IX 

Penalties and Regulations Governing 

Disputes 

Arto 63. A fine of 100 to 1,000 gourdes shall be imposed on 
any employer who: 

1. Fails to report to IDASH his enterprise and the number of 
his employees covered by insurance, or who makes tardy or incorrect 
declarations. 

2. Neglects to notify IDASH of an accident involving one of 
his workers. 

3. Neglects to make out regularly and to retain for submission 
to IDASH when necessary, the pay sheets and the register of insured 
persons in conformity with the provisions of Art. 29 of the present 
law. 


4. Neglects to keep the insurance cards or booklets and to 
affix thereto insurance stamps for each of his employees 3 

5* Neglects, without a valid excuse, to give the inspectors of 
IDASH the information requested, or gives false information. 

The same fine shall be imposed on anyone who prevents the 
representatives of IDASH from making inspections in connection with 
insurance. 

Art. 64. If a contribution is not paid at the required time, 
the employer in default shall pay a fine amounting to 10 percent of 
the amount unpaid for each month or fraction thereof in arrears. 

Art. 65. Any employer who has violated the provision in the 
last part of Art. 32 stipulating that the cost of accident insurance 
shall be borne by the employer, or who has deducted from an insured 
person 1 s wage amounts exceeding the share provided for by law shall 
be punished by a fine of 50 gourdes. This fine shall be imposed as 
often as there are workers or employees affected by the violation, but 
the total fines so imposed in a single case shall not exceed 1,000 
gourdes. Furthermore, the employer shall be required to reimburse 
his workers or employees for all amounts illegally deducted. 

Art. 66. Whenever an enterprise passes from one employer to 
another, the former employer shall, before the date on which IDASH is 




A-16 


given written notice of the change, be jointly responsible with the 
new employer for the discharge of the obligations deriving from the 
present law, for one year, after which all responsibilities shall 
devolve upon the new employer. 

For the purposes of the present law, a change in the employers 
directing an enterprise shall be deemed to have occurred whenever one 
person acquires all or the greater part of the property of the former 
employer and uses it for the same enterprise. 

Art. 67o Insured persons or their beneficiaries who continue 
to draw cash benefits after a cause for suspension or cancellation has 
occurred shall repay the amounts illegally drawn with interest at 
12 percent a year, without prejudice to the penalties provided for in 
the criminal law. 

Art. 68. Insured persons or their beneficiaries who obtain 
insurance benefits by simulation shall likewise be required to return 
the benefits illegally obtained and, in addition, to pay a fine 
ranging from 5 to 100 gourdes. 

Art. 69. Violations of the present law for which no special 
penalty is provided shall be punished by fines ranging from 25 to 
500 gourdes. 

Art. 70. Violations of the present law shall be declared in 
reports prepared by the representatives of IDASH in the form prescribed 
by the regulations. 

Art. 71. The fines provided for in the present law shall be 
applied administratively by the Director of IDASH on the basis of the 
report of the violation. The penalties imposed by IDASH shall be 
enforceable according to the same procedure as that used for the payment 
of State taxes. 

Art. 72. To be admissible to file a complaint against a fine 
imposed by the Director of IDASH, the person concerned must first furnish 
proof of having paid the fine in full. 

The claim must be filed within a maximum of 5 days, aside from 
the time allowed for distance, from the date of notification of the 
imposing of the fine. It shall be presented before the civil court 
having jurisdiction over the employer and shall be judged as a summary 
proceeding. 

Art. 73. For remedies against any decision made by IDASH with 
respect to the obligation to be insurtic^ the amount of contributions, 


A-17 


the rights of the insured, benefits and the amounts thereof and in cases 
of disagreement between employer and Insured, the persons concerned may 
appeal to the civil court having jurisdiction over the employer. The 
appeal shall not stay the effect of the decision, 

X 

Investments 


Art, 74, IDASH shall hold as available funds only the amounts 
necessary for its immediate needs; the remainder of its receipts shall 
be converted into investments. 

Art, 75° The funds of IDASH shall be invested under the best 
conditions of security and interest yield, preference being given 
under equal conditions to investments presenting the greatest social 
utility. 

These investments must be made in such a way that the average 
return is not less than the rate of interest serving as the basis for 
actuarial calculations, IDASH shall make its investments according 
to the plans drawn up by the Director with the approval of the Council 
of Administration, 

These plans shall relate to a limited and reasonably fixed 
period; they shall contain the general lines and limitative percentages 
for each category of investment. 

Art. 76. The funds of IDASH shall be used in particular for: 

1, The general expenses of administration; 

2, The payment of benefits; 

3, The acquisition, construction, and maintenance of hospitals, 
sanatoriums, clinics, maternity homes, and other buildings intended for 
the use of the Administration; 

4, The organization of national workshops and enterprises 
established on an income-producing level; 

5, Loans and mortgages especially for low-cost housing or 
workers * settlements; 

6, Interest-bearing loans adequately guaranteed according to 
the conditions determined by special regulations, to private welfare 
organizations (hospitals, asylums, etc.) and producers' cooperatives. 



A-18 


The annual proceeds from the utilization of investment capital 
shall serve to improve the health and working conditions of the 
workers, according to the plans prepared by the Department of Laboro 

XI 

General Provisions 


Arto 77o The recipients of benefits in cash or in kind shall 
be obliged to comply with the regulations adopted to ensure the 
execution of the present law. 

Any violation of the provisions of the present law shall result 
in suspension of the benefits allowed under the insurance system. 

Arto 78. Benefits shall likewise be suspended if the recipient 
goes to a foreign country, unless there is an agreement between him 
and IDA3H as to the duration of his absence. 

Members of the family of an insured person shall not be entitled 
to compensation if they do not reside in Haiti. 

Art. 79o If, after an allowance has been fully paid to one or 
more beneficiaries of the insured person, others present themselves 
and, give proof of equal or superior rights, the injured beneficiaries 
shall have no claim whatever on IDASH, but only on those who enjoyed 
the benefits illegally or had only a limited right to them. 

In case of a periodic allowance, the necessary arrangements for 
future payments shall be made by IDA.SH, but it shall, incur no 
responsibility with regard to payments already made. 

Art. 80. HASH may revise the amount of benefits as a result 
of inaccuracies in the data which served as the basis of calculation 
in the case of pensions and death benefits. If the purpose of the 
revision is to reduce the pension or withdraw the right to the pension, 
it shall not be retroactive with regard to pension already paid, 
unless the granting thereof was based on an illegal claim or false 
declarations, in which case full restitution shall be required. 

Art. 81. Cash benefits paid to the insured shall be non- 
transferable and immune from attachment. 

Art. 82. For the purposes of the present law, HASH shall have 
the authority to inspect working places. The employers and workers 
shall facilitate the inspection in such a way that it may be quickly 




A-19 




and efficiently madeo The judicial and police authorities shall provide 
any assistance requested by IDASH in order to exercise its functions 
under the best conditions, 

Arto S3. The following advantages shall be accorded to the 
Social Insurance Institute of Haiti: 

I* Exemption from taxes on movable and immovable property, 
except taxes relating to the prestation of public services exclusively 
(water taxes, telephones, etc.). 

2. Exemption from dustoms duties on the goods or articles 
imported by IDASH solely for its own use; 

3. Exemption from the use of stamped paper and from registry 
stamps and duties; 

4. Immunity of its property, funds, and income from attachment. 

, • • 

Art. 84e The Director of IDASH shall each year publish as 
detailed a report as possible on the following items in particular: 

(a) The total receipts collected; 

(b) The use of the funds obtained; 

(c) The profits realized; 

(d) The number of persons subject to compulsory insurance 
according to branch of activity; 

(e) Statistics on sickness and industrial accidents. 

XII 

Transitional Articles 

Art. 85c The present law repeals decree-law No. 268 of 
May 17, 1943, creating the Social Insurance Fund, The liquidation of 
the said fund shall be entrusted to the Social Insurance Institute 
of Haiti (IDASH). 

The net assets of the said Fund shall be transferred to IDASH 
for the formation of a working capital and guarantee fund and for 
the payment of any Oompensation claimed under decree-law No. 268. 



Art. 860 In order to meet the expenses of establishment, 

IDASH is hereby authorized not to pay the benefits in cash or in kind 
provided for by the present law until 6 months from the date on which 
the institution commences to function* 

Art* 87* The present law annuls all laws or provisions of laws 
and all decree-laws or provisions of decree-laws in conflict with it, 
and shall be executed by the Secretaries of State for Labor, Finance, 
National Economy, Commerce, Interior, and Justice, each in so far as 
he is concerned. 

Done at the Chamber of Deputies, Port-au-Prince, October 7, 1949 
the one hundred and forty-sixth year of Independence. 

Do Michel, President ad interim 

M, Maignan, F. Dufanal, Secretaries ad interim 

Done at the Maison Nationale, Port-au-Prince, October 10, 1949, 
the one hundred and forty-sixth year of Independence 

J. Belizaire, President 

E. Eliz^e, B. Boisrond, Secretaries 

IN THE NAME OF THE REPUBLIC 

The President of the Republic hereby orders that the above law 
be stamped with the Seal of the Republic, printed, published, and 
executed. 

Done at the Palais National, Port-au-Prince, October 15, 1949, 
the one hundred and forty-sixth year of Independence. 


Dumarsais Estime" 


By the President: 

Dr. Francois Duvalier 

Secretary of State for Public Health and Labor 
Nod" Fourcand, Jr. 

Secretary of State for Finance and Comnerce 
Lucien Hibbert 

Secretary of State for Agriculture and Economy 
Louis Raymond 

Secretary of State for the Interior, Justice, and National Defense 
Dr, Vilfort Beauvoir 

Secretary of State for Foreign Relations, Tourism, and Worship 
Raymond Doret 

Secretary of State for National Education 
Pierre Nazon 

Secretary of State for Public Works 


B-l 


Appendix B 


Work Accidents and Compensation 

on Three Sisal Plantations 


There are no general data on the frequency of work-connected 
accidents and injurieso However, the Bureau of Labor had some 
fragmentary data based upon the experience of some large employing 
establishments which make periodic or occasional monthly reports„ 

The available data were compiled and tabulated for six large estab- 
lishments$ and they were supplemented by data collected from other 
sources for these employing units, or on the occasion of field visits,, 
The data for three large sisal plantations (including office, factory 
and farm employees) are covered in the following notes,. 

Sisal Plantation A 


The Department of Labor furnished some tabulations which 
summarize work accidents at this plantation (growing and processing 
sisal) for periods aggregating 14 months—7 months in the year 1949 
(January'-May and November-December, inclusive) and 7 months in the 
year 1950 (January-May and July-August, inclusive) 0 


During the 14 months covered by the tabulations there were 
reported— 


Total work accidents... 
Disabling (time loss) 
I* atal ooo»».o*oo.*.ooo 
Non-disabling (ld-6-).. 


o o o o 


o o CO 

© o o o 


143 

7 

2 


152 


The 

45, 48, 58 


The 


fatal cases occurred to males whose ages were; 18, 35, 39, 
and (l) unknown„ 

sex distribution of these accidents was as follows— 


MaleSoeooooooo 

Femaleso.. 

Not recorded,,. 


« o ♦ * 

• o o © 

o o o o 


o o o 

• o o 

9 © O 


124 

10 

18 


Among the 143 non-fatal, disabling accidents there were 
altogether 1,933 days of incapacity, equal to 13 0 6 per case, and to 
13e8 per case involving 1 or more days of disability,, These disabling 
cases involved from 1 day up to 2 months oi incapacity,. They do nofc 
include accidents involving less than 1 day of incapacity,, Their 
distribution by duration was as follows— 











B-2 


Duration 

Cases 

Total days of disability 

0 days 

2 

n _n lllirir 


1 day 

1 

1 


2 days 

2 

4 


3 days 

2 

6 


4 days 

-— 

——— 


5 days 

— 

——- 


6 days 

——• 

—— 


7 days 

c “ > “~ 

— 


8-14 days 

73 

730 


15-21 days 

43 

658 


22-28 days 

12 

264 


29-30 days 

5 

150 


2 months 

2 

120 


Total 

142 

1,933 


Unknown 

3 

(7) 


All durations 

145 

1,933+ 


Days per case. . 



13,6 

Days per disability 

CSLS0 © • o • o o 

oeocooao o oooooo 

13.3 


In the period to which the data apply, the average total 
enployment was about 6,300 (including about 5^000farm laborers). 
Thus, the reported accidents indicate tha following approximate 
rates- 


Number per 1,000 
employees per annum 


Fatal accidents ,.<>• e ,«,..«. 


• 0900000 


Jv^n-fatal (disabling) accidents 0 ..« 
0 ys of disabilityo9.oo.oeo*o*>e**oc 


0,95 

19o7 

266 


T, plantation reports that it pays one-half wages during 
incapacity aused by work-accident until recovery or death. In 
fatal case , various kinds of settlements are made, usually payment 
of about *2,000 in each case. With an average wage of about 027 per 
week, the cost of wage-loss benefits in 1949=50 was approximately as 
follows— 


Perce it cf 
payr 1 

\ i ■■ 1 —— ■■ — — r mm mm —— 

Fatal accidents,,,oo..o.ooless than 0,3 
Non-fatal accidents,..., 0 o 05 

Total,.............less than 0,' 5 


< 











B-3 


These figures do not include the costs of medical benefits 
which Are quite extensive at this establishment.^ The plantation has 
hospital facilities 5 (12-15 beds) Available at a nearby town, and 2 
clinics, 2 physicians, 2 nurses, and attendants on its own grounds; 
also, it uses'the hospitals'and physicians at a nearby public general 
hospital and in Port—au-Prince’ when' cases need more extensive or more 
specialized-care than can be furnished in its own facilities or nearby. 
Medical care (physician, etc. services, hospital or clinic care, 
medicines, ^etc.) are furnished free to employees—and largely free 
also te dependents, though the physicians mAy charge ‘fees in non-work- 
'connected cases. 

Information was obtained to the effect that the total costs at 
this establishment were about"$30j000 per year-.-of;which about $22,000 
was paid for medical, eld., services. 'The data' on.fatal and non-fatal 
accidents indicate (independently) payment* of about $8,000 a year for 
wage-loss in work accidents. ' Thus, with a total payroll of about 
$30,000-$35,000 per weekf/ total costs were about 1.6 percent of 
payroll .1/ Adjusted downward for services not directly resulting 
from work-accidents,-the annual expenditures probably equal about 
1.25 percent of payrolls.. 

Sisal Plantation B 

• ’ • * ». ’• ■* 

The Department of Labor furnished tabulations showing 40 non- 
fatal work accidents at this plantation and processing factory during 
periods aggregating 10 months (5 in 1949 and 5 in 1950). Neither 
duration nor indemnification was recorded for many of the cases. 

The management advises that,'in work injury cases, it is the 
practice to pay full wages ‘for 15 days, and then either full or l/2 
wages depending on the' employee, number of dependents, etc. In fatal 
case's, a caslj settlement is made ($500-$l, 00.0 per case). For medical 
care 1 , a new dispensary was under construction (October 1950); it is 
to have 4 beds. There is a dispensary on the farm, with a physician 
and nurses.. About 90 .percent, of the accident cases go to a nearby 
public general hospital for. treatment (the plantation has a room 
reserved at the hospital on an annual basis).. . 

• ■ *■ " - *.■ . .. • ' ■; ■- . •.'■ 

This plantation has. about 2,200-2,500 employees (occasionally 
3,000 or more). It spent (1949) about- $14,000 for medical care, wage- 
loss payments, and death settlements. This equaled.about 2 percent of 
total wages. But since this included a considerable amount of medical 
care for dependents, the total.cost is in excess of .the amount charge¬ 
able’to work accidents and injuries. A deflated -figure for these cases 
would be between 1 and 1.25 percent of payrolls. 


1/ These calculations'agree with the information supplied at the 
establishment (October 1950) that their estimated total cost for 
work-accidents and related medical services (including preventive 
services) has been about 1-2 percent of payroll in each of the 
last few years. 





B-4 


Sisal Plantation C 


The Department’s reports cover 29 non-fatal work accidents in 
the 9 months January-September 1949. Duration of incapacity (for 28 
of the cases) was distributed as follows— 

Duration Cases 


1 day 

2 

2 days 

3 

3 days 

4 

4 days 

2 

5 days 

6 

6 days 

2 

7 days 

2 

8 days 

1 

10 days 

2 

11 days 

1 

15 days 

2 

17 days 

1 


Indemnification was paid for a total of 170 days of incapacity 
(5«9 days per case), at the average rate of 03.65 per day Q Aggregate 
indemnity payments were 0620.50 ($ 124 ). 

The plantation management advised (October 1950) that it usually 
has from 800-1,500 field workers, with the number rising as high as 
3,000 on some days; and 600-700 office and factory workers. It pays 
all medical and hospital costs for work accidents and injuries until 
they are cleared up and discharged. It has a resident physician (full 
time), its own dispensary, and provides medicines, etc. It has an 
agreement for hospital care at a nearby public general hospital. It 
occasionally uses public wards but more often uses semi-private and 
private rooms at the hospital, depending on the employee’s job. It 
pays full wages while the employee is receiving medical care. In 
fatal cases it would make appropriate cash settlement; but it has had 
none during the tenure of the present management. In non-work-connected 
cases, it may pay the cost of medical and hospital care. It pays full 
wages for 15 days in periods of sickness. The patient may, in addition, 
take his accumulated annual sick leave (up to 15 days). The combination 
of sick-pay and annual leave usually means full pay during sickness. 

If the patient is still sick after exhausting these periods, the 
management may continue to pay full or 1/2 wages. 

Fragmentary data suggest that this plantation is incurring a 
cost of about 1 to 1.5 percent of payroll, possibly less, for work- 
connected accidentso 





APPENDIX C 


Appendix Tables X-19 

























Appendix Table 1 


Population of the Republic of Haiti 
August 1950 


Departement 

Arrondissements 

Population 

Total 

North 

1. Cap-Kaitien 

2. Trou 

3. Gde Riviere du Nord 

4o Valli^res 

5o Fort-Libert^ 

60 Plaissance 

7a Limb^ 

8 . Borgne 

119,039 

52,343 

106,366 

43,101 

64,353 

57,244 

40,053 

57,697 

540,196 

Northwest 

1 0 Port-de-Paix 

2 0 Mole St. Nicolas 

115,850 

52,496 

168,346 

Artibonite 

1. Gonaives 

2. St 0 Marc 

3. Marmelade 

4. Hinche 

5. Dessalines 

165,635 

96,894 

75,995 

100,503 

129,639 

568 ,666 

West 

1. Port-au-Prince 

2. L^ogane 

3 <, Jacmel 

4. Saltrou 

5a Mirebalais 

6a Lascahobas 

424,168 

211,163 

246,405 

56,926 

114,255 

41,593 

1,094,510 

South 

1. Les Cayes 

2. Aquin 

3» Coteaux 

4a Grand Anse 

5. Tiburon 

60 Nippes 

195,593 

123,907 

56,248 

175,230 

47,031 

142,162 

740,171 


Total 0 aooae ooaoeoaa ... eooa 

Less 84 out of the country 
Adjusted total . 0 0 »« a © 

3 , 111,973 

84 

3,111,889 


Source: Recensement de la Republique d 8 Haiti . Bureau de 
Recensement, D^partement de 1*Economie Nationale . 












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I ^ g 
» 


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• «n • 

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u l 

§ *a 

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u fl 

Iks; 

g O t> B 

I I I 


j; i 

^ o 

S OH 

3 fr 


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; 9 2 


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a » 



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I H I H I 


I t* » © « I • 


I | H H W H | 


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I CM rH I J NAB I | 


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>» 



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4 

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3 


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3 

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Appendix Table 4 


Average Earnings of Employees in Private Employment 
with Monthly Salaries of More Than #500 

(Based on a special survey, April 15, 1950) 


City 


Number Average (#) 


Cap~Haitien 0 © <> 

Fort Liberty „. a «. * „ 
Limonade 0 » 00 
Port-de~Paix< 
Gonaives, 
Port-au-Prince, 
Jacmel< 


ooooooooooooo 

o o o o o o o 

oooooooooooooeo 
• c o o O OOOOO O o o O o o 

» O OOOOOOOOOOOOO OOOOO 
•OOOOOOrtOOOOOO 

.oooooooo ooooconoooooo 

Petrt Goave ©©oo©oonoo©ooooo 

J Qoooooooooooooooooooo 

► ft ooooo o o ©o ooooo o o o 


Les Cayes, 


7 

5 

1 

1 

3 

140 

1 

1 

1 

2 


All cities 


0OOOOOOOOOO© 


760 0 71 
6 l0 o 00 
625©00 
625o00 

666067 

824oil 
l^OOOoOO 
750o00 
750o00 
812© 50 


162 


809©41 








Appendix Table 5 


Employees Covered by the First Survey 
of Public Employments 1950 


Office 


Number of 
employees 


Imprimerie de l r 2tat„ <>»<, <,«. 

Finances I. oooooooeoocooo© 

R^gie du Tabac * <> © c © o © © 0 ©o © 
Loterie Etat Haitieno *oo©* 

Al*Cl*lXV0 So ooe o o ooooooooooo o 

E xnan 00 s 3 -.-ooooooooo©oopoo 

f^l^phons SoOOrtOOOOOOOOOOOO 

Economie Nationale,©© oo ©© o 

T OUT X S HIS ©ocoooooooooooooo© 
JllStxCS 000000009 oocooooooo 

0 Ult 0 Soo®oooooo©oooooooooo 

00 TTUI 101 * 00 o 000000 00 000000000 


000 o o o 

0 0 9 0 0 0 

00000 o 

00 0000 

0 0 0 9 0 0 

0000 00 

000000 

o o o o o o 

000000 

O O O o o o 

o o o o o o 

O O O O O O 


o * o 0000 

0000000 

0000000 

0000000 

O o o o o o o 

O O O O o o o 

o o o o © o o 

© o © o o c © 

0 9 0 0 0 0 0 

o o o c o 0 o 

O O O O O O O 

O O © O r* o O 


88 

185 

56 

29 

32 

41 

167 

28 

28 

18 

7 

22 








Appendix Table 6 


Employees Covered by the Second Survey of 
Public Employment; 1950-51 1/ 


Ministry 


Number of employees 1/ by 
monthly salary 

- 03Oo"and*~ 

Total less 0301-500 


A^riCUltUr© ooooococooooo 

0 0 

314 

241 

73 

Relations ExtdrieureSo o« 

0 0 

54 

40 

14 

Culte Soooooooooooooooooo 

0 © 

5 

4 

1 

0 0 mme i?C 6 o ooooooooo® ooo «c 

0 © 

132 

112 

20 

Bconomie Nationale 0 © o <> © © 

0 0 

24 

11 

13 

JUStiCe 0009 OOOOOOOOOOOOO 

0 0 

826 

806 

20 

Travailo ©000000000000000 

© 0 

75 

49 

26 

Education National© 0 © o © <> 

0 © 

2 a 242 

2*114 

128 

Sant^ Publique« „ 0 0 0 0 e »0 0 

0 © 

724 

619 

105 

Einaneesoo ©oo oooo © <■> oooo o 

© 0 

157 

29 

128 

-tnu^r leur ooooooooooooooo 

0 © 

132 

107 

25 

Travaux Publics 0 o© © © o© © 0 

0 © 

114 

49 

65 

All Ministries© © © © 0 

0 © 

4*799 

4*181 

618 


1/ Potentially subject : compulsory insurance if the limit 
is fixed at 0500 pe. month5 excludes employees earning 
' more than 0500 per month e 







Appendix Table 7 


Employees Covered by the Second Survey of 
Public Employment? 1950“51 1/ 


Ministry 


Number 

of employees 

1/ by departement 


Total 

North 

Northwest 

Artibonite 

West 

South 

OOOOOOOOOOOO 

314 

15 

13 

32 

223 

31 

Relations Exterieures 0 <, 

54 

3 



51 


0 So o ooo ooooo ©oooooo 

5 




5 


0omm© rc©o oo oooo o © o o o© © o 

132 

8 

4 

8 

99 

13 

Economie Nationale „» 0 « o 

24 




24 


OOOOOOOOOOOOOOOO 

826 

196 

55 

122 

239 

214 

T I* cl*V 3 » 0600 oo oooo oooooo 

75 

9 

4 

7 

47 

8 

Education Nationale „ e 0 <> 

2,242 

356 

104 

316 

1,145 

321 

Sant^ Publique <,. 0 « => 0 . • o 

724 

42 

15 

56 

564 

47 

FinanceSo oooooooooooooo 

157 




157 


Int^neur oooooooooooooo 

132 

9 

3 

12 

96 

12 

Travaux Publics , 0 o <>. <> • o 

114 

8 

5 

13 

78 

10 

All Minist rie s•• •o 

4,799 

646 

203 

566 

2,728 

656 


1 / Potentially subject to compulsory insurance if the limit is fixed at 
0500 per months excludes employees earning more than 0500 per montho 










Appendix Table 8 

Employees and Earnings in Public Employment; 1949-51 

Haiti 

(Third Survey of Public Employment) 


Ministry and office 


o © o o 

o o o © 

o © o © 


Education Nationale © * © © © o o 0 ©©© © 

o ooooo oo ooooooooo oeoo c oo 

Santa' IPubliQue p © o ooo©ooooooooo© 
Int^rleur 

Buncaillo o O OOO ©OOOO O O O OOO oooo o 

Prefecture de la R^publique 
Finances 
Bureau 

Departement Fiscal,,© 

Dept© Comm© (B©N©RoH©) 

R^jgie du Tabac 0 o 
Loterie Etat Haitien 
Archives Nationales 
Impr'imerie de l 8 Etat„ 

Adm© Gle© des Contributions. 
Agriculture 

Commerce 


OOOOO 


o O 

o o 

o o 

© o 

o © 


• OOO OOOO OOO OOO oooooo OO OOOO OOO 


OOOOOOOOO o o -e oo 


oooooooo • o © o 


oo ooooooooo oo® oooo 


kOOOOOOOCOOOO 


•o OOOOOOOOOOOO 


O O O O O o o 


'O ooooooooo oooooooooo 


OOO® 

oooo 

oooo 


Bureau 


OO OOOO ooooooooo ooooooooooo 


OOOOOO OOOOOO 


Looo ®oooooooooooo o oooo oo eo o 


•OOOOO ooooo oo oooooooo 


• OOOOOOOOO OOO OOO ooooooooo 


► ooooooooo©ooo©ooooo<a©oooo©ooo 


Adm e Gle 0 des Postes 
Relations Extdrieures 

Bureau 
Tourisme 
Travail 

Cultes 
Economie Nationals 

BUreaUO OOOOOOOOOOOO OOO 

Bureau Recensement 
Travaux Publics 

Bureauoooooo o o © © © ©oooo 
T^l^gr&phes Terrestres 
Service Hydraulique © © © 


©OOO 

OOO® 


o ooooo 


©ooo 

OOOO 

oooo 

oooo 

o © o © 


oooo 

oooo 

oooo 

oooo 

oooo 


o o 

e o 

o o 

o o 

o © 

O o 

o o 

o o 

o © 

o O 

o o 

o o 
o O 

o o 

o o 

o o 


T otaloooooo 


ooooooooeooooooO 


Number of employees 


by monthly salary 


Total 

(£300 and 
less 

0301-500 

0501 and 
more 

2,333 

2,114 1/ 

165 2/ 

54 2 / 

935 

806 1/ 

22 2/ 

107 2/ 

862 

619 1/ 

117 2/ 

126 2/ 

208 

50 1/ 

40 2/ 

118 2/ 

69 

52 1/ 

— 

17 2/ 

40 

16 2/ 

13 2 / 

11 2/ 

185 

79 2/ 

30 2/ 

76 2/ 

134 

48 2/ 

65 2/ 

21 2 / 

47 

21 2 / 

14 2/ 

12 2 / 

29 

17 2/ 

6 2/ 

62/ 

32 

30 2 / 

1 2/ 

1 2 / 

88 

66 1 / 

10 2 / 

12 2/ 

326 

120 2/ 

119 

87 2 / 

394 

241 1/ 

73 2 / 

80 2/ 

22 

12 2 / 

2 2 / 

8 2/ 

234 

208 1/ 

18 2/ 

8 2/ 

49 

26 2/ 

8 2 / 

15 2/ 

28 

14 2/ 

11 2 / 

3 2/ 

86 

49 1/ 

26 2/ 

11 2/ 

7 

4 U 

1 1/ 

2 2 / 

28 

12 2 / 

11 2/ 

5 2/ 

96 

60 2 / 

30 2 / 

6 2/ 

197 

64 1/ 

70 2/ 

63 a/ 

167 

133 1/ 

24 2 / 

10 J/ 

60 

32 1/ 

17 2/ 

11 y 

6,656 

4,B93 

893 

870 


1/ Source; Budget 1949-50 <> 
2/ Source; Budget 1950-51• 
Source; Special inquiry 

















Appendix Table 9 

Employees and Earnings in Public Employment: 1949-51 

Port-au-Prince 

(Third Survey of Public Employment) 


Ministry and office 


Number of employees by monthly salary 


0300 and 0501 and 

Total less 0301-500 more 


Education Nationale 

Justice ,, „ * 

Sants'* Publique 

Int^rieur 

Bureau 

Prefecture de Port-au-Prince 
Finances 
Bureau 

Departement Fiscal 
Dept, Commercial (B,NoR,Hc) 
R^gie du TabaCoe 
Loterie de l*Etat Haitien 
Archives Rationales 0 
Imprimerie de l’Etat 
Contributions 
Agriculture , *,<> 

Comnerce 
Bureau, 

Administration des Postes 
Relati o ns Exte r ieures 

Bureau o ooooooeooocoooooooooo. 

Office National du Tourisms, 0 
D^partement du Tra~va.il ,,,,,,,.,, 
Economie Nationale 

Bureau 00,0000000,0000 »»o,oooo 
Bureau Recensement, O ooo,o..oo 
Tra vaux Public s 

«—■ r irjn T») 

Bureau o oooooooeoeooooooooo»oo 

Tel^gr&phes. 00000,0000,000,00 
Service Hydraulique 0,00,0,0,0 

Cults S* oooooooooeooooaoooooooooo 


ooooorooooooo 

OOOOOOO® OOOOO OOOOOOOOO 

OOO OO ®OOOOOo OOO 090 

OOOOOOOOOOOOOOOOOOOOOOO 

o 

ooeoooooooo OOOOOOOO • o o o 

OOOOOOOOOOO 

o o 

OOOOO 00 000000 

0000 

O O O O OOOOO 

000000000 
o OOOC OOOOOOO 0000 
0000 0000 000000000 

oooooooooooooooooooooo 

0000 


Total,, 


0000 000O00OO0OOOO 


730 

551 y 

164 1/ 

15 1/ 

124 

741 / 

8 1/ 

42 1/ 

553 

434 2 / 

81 1/ 

38 1/ 

106 

58 2/ 

42 1/ 

6 1/ 

5 

4 2 / 

— 

1 y 

40 

16 2/ 

13 2/ 

11 2/ 

121 

45 2/ 

20-2/ 

56.2/ 

134 

48 2/ 

65 2/ 

21 2/ 

47 

21 2/ 

14 2/ 

12 2/ 

29 

17 2/ 

6 2/ 

6 2/ 

32 

30 2/ 

1 2/ 

1 2/ 

88 

66 2/ 

10 2/ 

12 2 / 

215 

52 2/ 

87 2 / 

76 2 / 

190 

97 1/ 

39 1/ 

54 1/ 

22 

12 2 / 

2 2/ 

8 2/ 

63 

37 2/ 

18 1/ 

8 1/ 

49 

26 2/ 

8 2/ ’ 

15 2/ 

18 

8 2/ 

8 2/ 

2 2 / 

58 

26 1/ 

19 1/ 

13 1/ 

28 

12 2/ 

11 2/ 

5 2/ 

96 

60 2/ 

30 2/ 

■ ' 62/ 

117 

40 2 / 

28 1/ 

'49 1/ 

167 

133 2/ 

24 2/ 

10 2/ 

49 

21 1/ 

17 1/ 

'll 1/ 

7 

42/ 

1 2/ 

■ ••• 2 . 2 / 

3,088 

1,892 

716 

480 


1/ Sources Budget 1950-51o 
2/ Source: Budget 1949-50 e 
2/ Source: Special inquiry. 






















Appendix Tcible 10 

Geographical Distribution of Physicians, by Errployraent 

(April 1950) 


Departements 

and 

localities 1/ 

Public 

Health 

Depart¬ 

ment 

Institute 
of Inter- 
American 
Affairs 

Army 

Industry 

Private 

practice 

Total 

000009000 9000 

14 

2 

3 

3 

7 

29 

Cap Haitien..... 

13 

——— 

2 

Utl M L*) 

6 

21 

Dondon oooooooooo 

——— 

1 

— 

—- 

—— 

1 

Gdc Riv» Nordo« 0 




* —— 

1 

1 

Li mb ^0 090# 0 0 • 0 c © 

1 


— 

—• 


1 

Pit. Dauphino.oo 

— 

——■ 

— — 

3 

— 

3 

Pxl.^^0 0000*0*900 

—— 

1 



_>— 

1 

Ouanaminthe 0 ..- 0 

——— 

—— 

1 

— 

—— 

1 

Northwesto•......» 

3 

— 

1 

—— 

3 

7 

Port de PaiXo.o, 

3 

— 

1 

<—— 

3 

7 

Artibonite. 0 ...••. 

12 

2 

3 

2 

10 

29 

Gonaiveso «..... 0 

5 


1 

-— - 

5 

11 

HrLnc]"i© 0 0 0 0 0 0 0 co 0 

4 

— 

1 


1 

6 

0 Marc 0000*000 

3 

-- 

1 

—— 

2 

6 

Mont RouiSo • • „ 0 0 

—- 

—— 


1 


1 

Pte 0 Riv 0 Art..,, 

—— 

—— 

=—■ 

—— 

2 

2 

0 9 9 0 0 0 0 

——— 

——- 

—— 

1 


1 

Perodo 

— 

2 

——- 

— 

— 

2 

"W© S"t* 00000000900000 

87 

5 

11 

2 

107 

212 

Port-au-Prince 6 . 

78 

5 

9 

2 

97 

191 

Xj^O^flJTl© OOOOOOOOO 

1 

—— 

—— 

——«= 


1 

Potion Villeo . 0 o 

—— 

——— 

-—- 

—— 

3 

3 

Ar 03.1x3.16 oo9o«*oo 

— 

——• 

— 

—— 

1 

1 

Belladere. ...... 

2 

.—— 




2 

Jac mel O9*o*o*ooo 

3 

—* 

1 


3 

r» 

/ 

Bai_2X©'*to 0009000 90 

— 

—— 



1 

1 

Mirebalais. „ 0 .. , 

—— 

— 

—— 

-- 

1 

1 

Petit Goave ...., 

3 

— 

1 

— 

1 

5 

0 9*0* 0 0 099000 

9 

4 

2 

— 

7 

22 

Cayr: 1 .......... 0 

5 


1 


3 

9 

Cav; ' lion. 

—. 

2 

■noacQ 

a»>— 

__ iMr 

2 

Pt 0 a Piment c0 .• 





1 

1 

J^rdmie oo*oo<»oeo 

3 

■—— 

1 

«= —— 

2 

5 

Moron ooo« *000000 

-— 

2 

—<— 

--— 


2 

Anse a Veau. „ 0 .. 

1 

—— 



- 

1 

Miragoane. ••••.. 

——■ 

ucaaoc 

— 

—— 

1 

1 

Total. 0 .. 

2/125 

13 

20 

7 

2/134 

299 


1/ Underscored localities have hospitals. 

2/ In other tabulations, 17 physicians who are here classified as primarily 
in private practice are classified in part- or full-time employment in 
the Department of Public Health. 
























Physicians Employed (Full Time or Part Time) in Hospitals and Health Centers 


2 

Jt 


U 

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Geographical Distribution of 86 Physicians by Specialization of Practice 


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p 

R 

Q 

• 


X 

r-4 

O 

-p 

J3 

M 

X 

© 


"O 

-p 

© 

P 

o 

*H 

O 

•ri 

•p 

p 

I o 

© 

aS 

© 

P 

© 

© 

Q 



X 

o 

X 

Ok 

p 

o « 

01 

to 

Ok CQ 


a, 

3 

.4 

*"3 




o 


o 


X 




« 




O 






S3 


S3 


< 




3= 

1 




CO 




CO 

CO 


CM 




CO 


o> 


o 

CM 


» CO 

I CM 

I 


$ 

o 

fH 
















Appendix Table 13 

Geographical Distribution of Dentists 


Departeraent and city 


Total 


Private 

practice 


Employed by 
Department of 
Public Health 


North 


Cap-Haitieno«„» 


Northwest 


© o o o o © 


Port-de-Paix 


Artibonite 


©oooooooo 


GOXl£LXVt^ So OOOOOOOOOOO C» 

Sis o Marc o©o©©oooo©oooo 

Hinche ooonooo®ooooooo 


West 


Port-au-Prince© © © 00 o © 
Leoganeoooooo©©©ooooo 

Jacrifcl ooeooooeooooooo 


3 

2 

2 


45 

1 

3 


4 

3 


2 

2 

1 


44 

1 

2 


South 

Miragoaneo«*«« 

Jer£mxs o * & coo 

Les Cayes„» oe „ 


o e 
c o 

o e 


1 

4 

4 


1 

3 

3 


Ail 


OOOOOOOOOOO 


74 


66 


2 


1 

1 

1 

1 


1 

1 

8 













Appendix Table 14 

Geographical Distribution of Pharmacists 


Number 

Departement and city of 

pharmacists 


Persons 

per 

pharmacist 


North 

Cap-Haitien,,«„. c . „ 


6 


90,033 


Northwest 

Port-de-Paix 


©ooooooo 


©ooooo 


2 


84,173 


Artibonite 


0000000*00000000 
ooooooooo©oo*ooooooo 


GonaiveSo• 

Hinche 
St. Marc. 

Petite Riv e Art 


000000000009000GO 

o ooooooo 


3 

0 

4) 

1) 


5 


West 


OoOOOOOOOOO© 

OOOOOOO OOO 

o © o o o 


Belladere ooooooo <>o«ooocooo 
Port-au-Prince 
P^tionvilleo <>« 

Croix des Bouquets, 

Ar caha^eoo©oooo©cooooooo 
Gressier ooooooo©oo**o* oo 

0 a o me 1 OCOOOOOOOOOOOOSOOPOO 

Grand-Gosier 
Marigot 
Bainet 
Petit Goave 


o oooooo ooooo 

ooooocooeo ooooooo 

©ooooooooooooooooo 

ooooooooooooooo 


S outh 
Jer^mifto 
Miragoane©.©. 
Les Cayeso„.. 
Aquin 


OOO OOOOOOOOOOOOOOO 
OOOOOOOOOOO 
OOOOOOOCVOOOOO 

O OOOOO v> OOO ooooooo O O 


0 

42) 

1) 

1) 46 
1) 

1) 

3) 

D 6 
1) 6 
1) 

2 


3) 

2 ) 

6 ) 

2 ) 


8 


oooooo 


83 


60,543 
44,507 


10,456 

41,067 

176,662 

44,452 

46,968 


All 


OOO 


37,494 








Distribution, by Hospital Districts, of Personnel ir the Division 
of Preventive Medicine, Department of Public Health 


2 

o> 

H 

I 

TJ 


« 

b 

© 

A 

•P 

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to 

>» a 

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as *h 
b C 

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■P 


3 


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•H 

•CO 


$ 

O 


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O 

•rt 

u 

-p 

CO 


cx 

a 

o 

EG 


CO 

to 


CM 


A 

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<-t to 

sj a> 

© w -a 
x: © *h 
w © 
o G 
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r-l p a 
x> © 

3 

a, 


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o 

CM 


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b 

«P 

CO 


to I 
I 
I 


5* CM CM 
CM 


CM 


I H W H | | CM 

* 1 ! 

I * II 


COCOlOCOfr-cOCMV 
rH CM 


CO 10 


»-» » » 


till 

till 


I I 


I I I I I I 

I I I I I 


H I I I I I © | | I H 

till* III 
I I I I I III 


VNlOHNHNtOlOtON 

CM 


O oo o a> at 0 O) o w ® 

tO H P H H 


8 


K 

a *h 

33 

•P I 

•H © 
© TJ 
W I 
I -p 
CX b 
© o 
o a, 


333 
g 


o 

a 


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o u 
u o 
n 
© 


t 

8 

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Cj tc CO » 


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8 

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b 
(X 

I 

3 

f 

-P 

b 

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(b *-3 (X, ^ 


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6 .H © 

o -p b 

.© © 


ca 


33 


Cayes 


























o 

fi 

•*"« 

U 

Cm 

I 

3 


+» 

t. 

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a. 



© 

B 

a 

o 

<n 

u 

© 

a. 

x 

4» 

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© 

tc 


I 


o 

4» 

© 


5 


a 

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o 

c 

r*4 

I 

I 


u 




o> 


a» 


<o 


(O 


00 


to 


(O 

CO 


r-t 

o 

El 

















Appendix Table 17 

Average Animal Earnings According to Earnings Limits 




Annual earnings 

($) per annum 


Employees and 
earnings 

aii y 

Public 2/ 

All 

Private 

Port-au- 

Prince 

Other 

1© .A.T*! 0 mployee Soooo\>©o©ooo 

478 

717 

451 

504 

367 

la. Excluding earnings 
in excess of 

0^000 mO e oooooooo 

439 

669 

413 

444 

358 

lb. Excluding earnings 
in excess of 

0300/mo o oooooooo 

387 

542 

370 

389 

334 

2 C Employees earning not 
more than 0500/mo e o o o <> 

375 

535 

357 

380 

343 

2ao Excluding earnings 
in excess of 

0300/mo © oooooooo 

363 

500 

348 

360 

326 

3o Employees earning 0301- 
0500 per montho oooooooo 

925 

9 S3 

919 

905 

958 

4o Employees earning not 

more than 03OO/mo o 00 oo 

327 

463 

312 

319 

300 

5. Employees earning 01X0- 
0150 per month® oooooooo 

301 2 / 

3io 2/ 

300 

302 

295 

6 0 Employees earning less 
than 0110 per montho® 0 c 

224 2/ 

247 y 

221 

216 

228 

7o Employees earning 0501 
per month and more 0 o o o o 

1*892 y 

1,440 y 

1,942 

1,978 

1,718 


1/ Public and private data combined by weighting 10 percent and 90 percent, 
respectively,* 

2/ Data from the first and second surveys of public employment combined by 
weightings in proportions according to the numbers of employees covered 0 
Applies to both Port-au-Prince and elsewhere 0 For data on public employees 
in Port~a.u~Prince and in all Haiti, see Appendix table 19» 

3/ For public employees, based on data from only the first survey; the second 
survey did not show subdivision of earnings below 0300 per month 0 
ij Assumes average earnings of 0600 per month for public employees 0 
















Appendix Table 18 


Average Annual Earnings and Amounts Subject to 
Insurance Contribution Rates 

Public Employees 


Employees and earnings 


OOOOOOOOO 09 0000000000000 


1. All employees* 

la» Excluding earnings in excess of 
$300 per montho oooooooooooeooo, 
Ibo Excluding earnings in excess of 
$300 per montho <.„ 


00(i>000*009*<»00 


2e Employees earning not more than $500 

JO0JT month OOOOOOOOOOO 00ft©00©000009000< 

2a 0 Excluding earnings in excess of 
$300 per month., 


I. OOOQOOOCOOOOOOOOO 


3o Employees earning $301-$500 per month, 

4» Employees earning not more than $300 
per month„ 6 „ 


ooooooooooooooooooooooooo 


5. Employees earning $110~$150 per month, 

6„ Employees earning less than $110 
per month, 


oooooeooooooooooo 00000900 <>oo 


7o Employees earning $501 per month 

and moreoc.oooooooooo*oo©ooo©ooooo©ooo 


Annual earnings ($) 
per annum 


First 

Survey 

Second 

Survey 

754 

713 1/ 

702 

665 

566 

540 

569 

530 

526 

497 

912 

996 

466 

463 

310 

(2/) 

247 

(2/) 

1,440 2/ 

1,440 


l/ Assumes (from first survey) that 20 percent are employees with 
$500 per month and more,, at average of $600 per month• 

2/ Not available this series lacks data necessary for the sub¬ 
division of earnings below $300 per month® 

Assumes $600 per month® 













Appendix Table 19 


Average Annual Earnings and Amounts Subject to 
Insurance Contribution Rates 

Public Employees in Port-au-Prince 
and in All Haiti; Third Survey 


Employees and earnings 


tooooooaooooooooooooooooooooo 


lo All employees, 

la 0 Excluding earnings in excess of 
$500 per montho 0 .® o • o»»»®o <>«.. < 
lb® Excluding earnings in excess of 
$300 per month, 


lOOeOOOOQOO OOOOO 09 000 


2 0 Employees earning not more than $500 

pci* month © 00 © 00 ©© 0 © 000 »» 0 # 0090000 © 0 © 

2ao Excluding earnings in excess of 
$300 per month®••••••••. 


oooooooooo 


3c Employees earning $301-500 per month 


00000 


4® Employees earning not more than $300 

per month oOOOOOeOOOOOOOOOOOOOOOOOOOOOOOO 


5 ® Employees earning $ 110-150 per month 


OOOOO 


60 Employees earning less than $110 

per montho ©©o©oooo©eoo©ooo©ooooooooo©ooo 

7 0 Employees earning $501 per month and more 


Annual earnings ($) 
per annum 


Port-au- 

Prince 

All 

Haiti 

840 

716 

710 

610 

572 

518 

638 

522 

544 

487 

994 

942 

478 

445 

322 

326 

240 

231 

2,038 

2,005 





















































































> 
























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